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THE 



HISTORY, DIAGNOSIS, AND TREATMENT 



FEVERS 



OF THB 



UNITED STATES 



THE 



HISTORY, 



DIAGNOSIS, and TREATMENT 



FEVERS 



UNITED STATES. 



BY ELISHA BARTLETT, M. D.. 

PROFESSOR OF MATERIA MEDICA AND MEDIC \L JURISPRUDENCE IN THE COLLEGE Off PHI - 
AND SURGEONS OF THE UNIVERSITY OF THE STATE OF NEW YORK; 
MEMBER OF THE AMERICAN ACADEMY 01 ARTS AND SCIENCES: 
AUTHOR OF AN ESSAY ON THE PHILOSOPHY OF MEDICAL SCIENCE, ETC. ETC. 



THIRD EDITION, REVISED 




PHILADELPHIA: 
BLANCHARD AND LEA. 

1852. 






All diseases, then, ought to be reduced to certain and determinate kinds, with the same exacfr- 
ness as we see it done by botanic writers in their treatises of plants. For there are N diseases that 
come under the same genus, bear the same name, and have some symptoms in common, which, 

notwithstanding, being of a different nature, require a different treatment In writing, 

therefore, a history of diseases, every philosophical hypothesis, which hath prepossessed the writer 
in its favor, ought to be totally laid aside, and then the manifest and natural phenomena of dis- 
eases, however minute, must be noted with the utmost accuracy, imitating in this the great 
exactness of painters, who, in their pictures, copy the smallest spots or moles in the originals. — 
Sydenham. 



Entered according to the Act of Congress, in the year 1847, by 

LEA AND BLANCHARD, 

in the Office of the Clerk of the District Court of the United States in and for 
the Eastern District of Pennsylvania. 



PHILADELPHIA : 
T. K. AND P. G. COLLINS, PRINTERS. 



TO 

JOHN ORNE GREEN, M.D., 

OF LOWELL, MASSACHUSETTS: 

With whom the early and active part of the writer's life was 
passed; in a personal friendship which no cloud, for a single 
moment, ever shadowed or chilled ; and in a professional inter- 
course whose delightful harmony no selfish interest nor personal 
jealousy ever disturbed ; this volume, the best materials for which 
were gathered during the period thus consecrated by useful labors 
and social duties, and now endeared to us both by many sad and 
pleasant memories, is most affectionately inscribed. 
November 1, 1847. 



PREFACE TO THE THIRD EDITION. 



I have very little to say in sending to the press this third 
edition of my book on fevers, but to express my obligations to 
the profession of the United States for the very favorable recep- 
tion which they have given to it. The general literature of fevers 
has, with one eminent exception, received no very important con- 
tributions since the date of the preceding Preface. The excep- 
tion to which I refer, consists in a series of papers published 
within the last year or two by Dr. William Jenner, of London. 
Their leading purpose is to show by careful and rigorous study 
and comparison the wide and fundamental differences which the 
author believes to exist between the several forms, as they have 
generally been regarded, of continued fever, and especially be- 
tween the typhoid and the typhus forms. Dr. Jenner's researches 
have enabled me to add largely to the fulness and completeness 
of the description of typhus fever ; and I have availed myself 
liberally of his facts and arguments in elucidation of the import- 
ant question of the true relations to each other of the two great 
forms, or species, of continued fever. 

I have given no account of the Relapsing Fever of Great 
Britain, as I do not know that it has ever been met with in the 
United States. 

College of Physicians and Surgeons. 
New York, June 1, 1852. 



PREFACE TO THE SECOND EDITION. 



It will be seen by those who have read the first edition of my 
book on fevers that the present is in some respects rather a new 
work than a new edition of the former. The History of Typhoid 
and of Typhus Fever remains much in the same state in the pre- 
sent as in the first edition, with such additions and development - 
only as further observation and study have enabled me to make. 
The History of Periodical, and of Yellow Fever, constituting 
one-half of the volume, has been added to the present edition : 
thus rendering the work what it professes to be, a Systematic 
and Methodical Treatise on the Fevers of the United States. 

November 1, 1847. 



PREFACE TO THE FIRST EDITION. 



I have written this book, because I thought that I saw a want 
in medical literature which it might supply. Our science, so 
far as the great subject of idiopathic fevers is concerned, is pass- 
ing through a transition period ; and many authorities, that were 
received as standard and classical only a few years ago, are fast 
becoming obsolete, at least for American readers. This is par- 
ticularly true of the leading English treatises on Fever. Neither 
the works of Fordyce, Armstrong, Southwood Smith, nor Tweedie, 
nor the elaborate articles on Fever in the Medical Cyclopedias, 
Libraries, and Dictionaries, can henceforth be regarded as suffi- 
cient or even safe guides for American practitioners ; and the 
remark is applicable to them, not because they are not works of 
great excellence and value, but for other reasons, which will be 
abundantly obvious in the course of the following pages. I may 
simply say, here, that their authors describe principally a fever 
or form of fever which is rarely met with in this country, and that 
they do not represent the actual state of our knowledge upon this 
subject. It must be regarded as especially unfortunate that, until 
within a few years, the greater part of our information relating 
to continued fever, has been derived from writers who have 
treated mostly, and under the same name as that generally used 
by ourselves, of a disease, or form of disease, differing in many 



Xll PREFACE. 

important respects from that which is most common with us, 
and that in this way so great a degree of confusion has been 
introduced into our notions of fever. 

If the radical defect in our literature of continued fever thus 
indicated had not existed, and if the histories of the disease 
which have been given to us by Louis, Chomel, and Andral 
amongst the French, and by Nathan Smith, Dr. James Jackson, 
Dr. Hale, and some others amongst ourselves, were generally ac- 
cessible, and generally read, there would have been no want such 
as I have alluded to ; and, certainly, I should not have added an- 
other to the long catalogue of books on fever. A translation, by 
Dr. Bowditch, of Louis's Researches, was published a few years 
ago under the auspices of the Massachusetts Medical Society, and 
has since been in the hands of most of its Fellows. But it is very 
far from being so generally and thoroughly known as it deserves 
to be. I may add, that the character of this remarkable work is 
hardly adapted to the actual wants and tastes of the great ma- 
jority of our practical men. I may say this, I think, without any 
risk of giving offence; for no man's admiration of this work can 
be more unqualified and profound than my own. Constituting 
as it does one of the few imperishable monuments that have 
from time to time, and at distant intervals, been raised up along 
the pathway of our science, it is nevertheless true that, in the 
present state of the profession in this country — amidst the daily 
cares and duties of its active members — there are but few who 
will devote to this object the time and the labor which are neces- 
sary thoroughly to comprehend its principles and to master its 
accurate and minute details. Chomel's Clinical Lectures, so far 
as I know, have not been published here; Nathan Smith's Essay, 
excellent as it is, is still very incomplete ; and the Reports of Dr. 
Jackson and Dr. Hale, besides not professing to treat systemati- 
cally of the disease, are not generally accessible. 

These, in brief, are the reasons which have prompted me to 
undertake the preparation of this treatise. I thought that the 



PREFACE. Xlll 

wants -of medical science, here at least, demanded a history and 
comparison of the two chief forms of continued fever, as they are 
now ascertained to exist, fuller and more discriminating than had 
yet been written ; and these wants I have endeavored to supply. 
My book aims at no other excellence, and no higher merit, than 
that of being a methodical and compendious summary of the 
actual state of our knowledge upon two most common and most 
important diseases. If it has reached this excellence, and if it 
possesses this merit, I am satisfied. 

I have only to add in conclusion, that one of my leading pur- 
poses has been to bring out more clearly and strongly than has 
hitherto been done our means of diagnosis between the different 
species or forms of fever, and to ascertain and establish their 
nosological relations. It cannot be necessary to go into any formal 
vindication of the importance of this diagnosis. Setting it aside 
altogether, as a matter of science, it is the first essential condi- 
tion of all sound practice. In the following history it will be no- 
ticed that I have spoken of no individual fever excepting the 
four which are more or less fully described; to wit, Typhoid 
Fever; Typhus Fever; Periodical Fever, in its three forms of 
Intermittent, Bilious Remittent, and Congestive ; and Yellow 
Fever. The simple reason of this is, that I do not know any- 
thing of any other distinct fever amongst us. There may be such 
a disease as the Simple Fever of Fordyce, or the Ephemera of 
many writers. I know that adults, sometimes, in consequence 
of great or protracted fatigue, and that children still oftener, 
from inappreciable causes, are attacked with headache, loss of 
appetite, debility, and general febrile excitement, not referable to 
any local origin ; which symptoms, after rest of from one to two 
or three days, either with or without medicine, usually subside, 
leaving the individual in good health. But whether this kind of 
disorder should be looked upon as a distinct established form of 
fever, seems to me, to say the least of it, very doubtful. As to an 
Inflammatory Fever distinct from Typhus or Typhoid Fever, I 



XIV PREFACE. 

can only say, with Nathan Smith, and Chomel, that I have no 
knowledge of any such disease. 1 

1 Mr. James Moore, Surgeon, says : " Synocha, or pure inflammatory fever, is 
a disease so rare in this country, that many experienced practitioners have doubted 
its existence." The same writer says that Culleh acknowledged that he never saw 
the disease. 

Dr. Thomas Bateman, a sensible and judicious writer, says: "With respect to 
Synocha, Dr. Cullen's distinguished successor, Dr. James Gregory, asserted that, 
during thirty years' practice, he had never seen a purely inflammatory fever uncon- 
nected with acute inflammation of some organ ; and my own subsequent experience 
entirely coincides with that assertion. It cannot be doubted, as Dr. Gregory re- 
marked, that the cansus, or ardent fever of the ancients, was the endemial bilious 
remittent of hotter climates, and that no continued fever of this country assumes 
that character." — A Succinct Account of the Contagious Fever, etc., p. 25. 

I may add, further, that the affection described by most of our systematic writers 
under the name of Infantile Remittent Fever, seems to me to have no existence as a 
distinct disease. Gastro-intestinal irritation, bilious remittent fever, typhoid 
fever, and still other diseases are confounded under the foregoing term. 

September 1, 1842. 



CONTENTS. 



PART I. 
TYPHOID FEVER. 



CHAPTER I 






PAGE 


Preliminary Matters .... 4'.» 


Am. I. — Introductory 






49 


Art. II. — Names of the Disease 






50 


Art. III. — History .... 






62 


Art. IV. — Methods of Description . 






U 


CHAPTER II. 


Symptoms ...... 56 


Art. I. — Mode of Access . 






56 


Art. II. — Febrile Symptoms 






58 


Sec. 1.— Chills. 






58 


Sec. 2.— Heat and State of Skin 






59 


Sec. 3.— Pulse .... 






61 


Art. III. — Thoracic Symptoms 






62 


Sec. 1. — Respiration 






62 


Sec. 2.— Cough 






63 


Sec. 3. — Physical Signs 






63 


Art. IV. — Cerebro-spinal, or Nervous Symptoms 






68 


Sec. 1. — Headache 






64 


Sec. 2. — Pains in the Back and Limbs . 






64 


Sec. 3.— Mind .... 






65 


Sec. 4. — Physiognomy . 






68 


Sec. 5. — Somnolence 






68 


Sec. 6. — Vigilance 






68 


Sec. 7. — Senses .... 






69 


Sec. 8. — Muscles 






69 


Art. V. — Digestive and Abdominal Symptoms 






72 


Sec. 1. — Tongue and Mouth 






72 


Sec. 2. — Appetite and Thirst . 






73 


Sec. 3. — Nausea and Vomiting 






73 


Sec. 4.— State of Bowels 






74 



XVI 



CONTENTS. 



Sec. 5. — Abdominal Pains 
Sec. 6. — Tympanites . 
Art. VI. — Miscellaneous Symptoms 
Sec. 1. — Emaciation 
Sec. 2. — State of the Urine 
Sec. 3. — Epistaxis 
Sec. 4. — Cutaneous Eruptions . 
Sec. 5. — Eschars 



CHAPTER III. 

Anatomical Lesions .... 

Art. I. — Lesions of the Circulatory Apparatus 

Sec. 1. — Heart and Aorta 

Sec. 2.— State of the Blood . 
Art. II. — Lesions of the Respiratory Apparatus 

Sec. 1. — Lungs 

Sec. 2. — Bronchiae, Epiglottis, &c. 
Art. III. — Lesions of the Brain and its Membranes 
Art. IV. — Lesions of the Digestive and Abdominal Organs 

Sec. 1. — Pharynx and (Esophagus 

Sec. 2. — Stomach 

Sec. 3. — Small Intestines 

Sec. 4. — Large Intestine . • 

Sec. 5. — Lymphatic Glands 

Sec. 6. — Spleen 

Sec. 7. — Liver . 

Sec. 8. — Pancreas; Salivary Glands; Urinary Apparatus; and 
Sexual Organs 
Art. V. — General Remarks 



Causes. 



CHAPTER IV. 

Sec. 1. — Locality 

Sec. 2. — Season 

Sec. 3. — Contagion 

Sec. 4. — Exemption from Second Attacks 

Sec. 5. — Epidemic Influences . 

Sec. 6. — Age .... 

Sec. 7.— Sex .... 

Sec. 8. — Race 

Sec. 9. — Occupation . 

Sec. 10. — Recency of Residence 

Sec. 11. — Filth, Crowding, &c. 

Sec. 12. — Exposure; Excesses, &c. 



CHAPTER V. 



Varieties and Forms 



129 



CONTENTS. 



XV11 



CIIAPTER VI. 



Duration, March, and Complications 
Art. I. — Duration 
Art. II. — March and Complications 
Art. III. — Peritonitis 
Art. IV. — Relapses. 
Art. V. — Sequelae . 



PAGE 

134 
135 

136 
137 
138 



CHAPTER VII. 



Mortality and Prognosis 



139 



CHAPTER VIII. 



Diagnosis 



in 



CHAPTER IX. 



Theory 



159 



CHAPTER X. 



ATMENT ...... 


167 


Art. I. — Dr. Jackson's Method . 


168 


Art. II. — Dr. Nathan Smith's Method 


171 


Art. III. — Chomel's Method 


174 


Art. IV. — Louis's Method .... 


170 


Art. V. — Bouillaud's Method 


182 


Art. VI. — De Larroque's Method . 


183 


Art. VII. — Miscellaneous .... 


184 


CHAPTER XL 





Definition 



188 



CHAPTER XII. 



Bibliography . 



190 



XV111 



CONTENTS. 



PART II. 








TYPHUS FEVER. 


CHAPTER I. 


PAGE 


Preliminary Matters ....... 197 


Art. I. — Introductory . „ . . . . 197 


Art. II. — Names of the Disease . . . . .199 


CHAPTER II. 


Symptoms ...... 200 


Art. I. — Mode of Access 




N 


200 


Art. II. — Febrile Symptoms 






201 


Sec. 1.— CMlls 






201 


Sec. 2. — Heat and State of Skin 






202 


Sec. 3.— Pulse ..... 






203 


Art. III. — Thoracic Symptoms 






204 


Art. IV. — Cerebro-Spinal, or Nervous, Symptoms . 






206 


Sec. 1. — Headache, Pains in Back and Limbs 






206 


Sec. 2.— Mind ..... 






207 


Sec. 3. — Physiognomy .... 






210 


Sec. 4. — Senses .... 






212 


Sec. 5. — Muscles 






212 


Art. V. — Digestive and Abdominal Symptoms 






213 


Sec. 1. — Tongue and Mouth 






213 


Sec. 2. — Appetite . . . 






214 


Sec. 3. — Nausea and Vomiting 






214 


Sec. 4. — State of Bowels 






215 


Art. VI. — Miscellaneous Symptoms 






217 


Sec. 1. — Emaciation 






217 


Sec. 2. — State of the Urine 






217 


Sec. 3. — Epistaxis 






218 


Sec. 4. — Cutaneous Eruptions . 






218 


Sec. 5. ( — Eschars 






224 


Sec. 6.— State of the Blood . 






224 


CHAPTER III. 


Anatomical Lesions .... . 226 


Art. I. — Lesions of the Thoracic Organs 






227 


Sec. 1. — Lungs 






227 


Sec. 2. — Larynx and Pharynx . 






228 


Sec. 3. — Heart and Blood 






229 


Art. II. — Lesions of the Brain 






230 


Art. III. — Lesions of the Abdominal Organs 






232 


Sec. 1. — Stomach 






232 



CONTEXTS. 



XIX 



Sec. 2. — Intestines 
Sec. 3. — Miscellaneous 
Sec. 4. — General Remarks 



PAGE 

232 
236 



Causes 



CHAPTER IV. 








238 


Sec. 1. — Locality 






238 


Sec. 2. — Season, Weather, &c. 






241 


Sec. 3.— .-Contagion 






243 


Sec. 4. — Epidemic Influences . 






248 


Sec. 5. — Crowding; Filth; Famine, &c. 






249 


Sec. 6. — Age .... 








Sec. 7.— Sex .... 








Sec. 8. — Recency of Residence 






264 



Varieties and Forms 



CHAPTER V. 






CHAPTER VI. 



Duration and March . 
Sec. 1. — Duration 
Sec. 2. — Crises 
Sec. 3. — Sequelee 
Sec. 4. — Relapses 



259 
262 

263 



Mortality and Prognosis 



CHAPTER VII. 



264 



[S 


CHAPTER VIII. 


272 


Sec. 1. — Symptoms 


. 


273 


Sec. 2. — Lesions. 




275 


Sec. 3. — Causes 




276 


Sec. 4. — Duration 




277 


Sec. 5. — Effects of Remedies . 


277 


Sec. 6. — Historical 


CHAPTER IX. 


278 



Theory 



322 



XX 



CONTENTS. 



CHAPTER X: 



Treatment 

Sec. 1. — Bleeding 

Sec. 2. — Purgatives 

Sec. 3. — Affusions and Ablutions 

Sec. 4. — Stimulants and Tonics 

Sec. 5. — Miscellaneous 



PAGE 

324 
324 
328 
328 
329 
331 



CHAPTER XI. 



Definition 



335 



CHAPTER XII. 



Bibliography 



337 



PAET III 



PERIODICAL FEVER. 



CHAPTER I. 



Preliminary Matters . 
Art. I. — Introductory 
Art. II. — Names of the Disease 



347 
347 

349 



CHAPTER II. 

Symptoms 

Art. I. — Mode of Aecess . 
Art. II. — Febrile Symptoms 

Sec. 1.— Chills 

Sec. 2. — Remissions or Type 

Sec. 3. — State of Surface 

Sec. 4. — Heart and Pulse 
Art. III. — Thoracic Symptoms 
Art. IV. — Cerebro-Spinal or Nervous Symptoms 

Sec. 1. — Headache ; Pains in Back and Limbs 

Sec. 2.— Mind 

Sec. 3. — Senses and Physiognomy 

Sec. 4. — Muscular Strength 



350 
350 
351 
351 
352 
355 
357 
357 
358 
358 
358 
360 
360 



CONTEXTS. 






XXI 


PACK 


Art. V. — Digestive, and Abdominal Symptoms . 361 


Sec. 1. — Tongue and Mouth 






S61 


Sec. 2. — Appetite and Thirst . 






362 


Sec. 3. — Nausea and Vomiting 








Sec. 4. — Epigastrium and Abdomen 






. 


Sec. 5. — Bowels 






364 


Sec. G. — Urine .... 






866 


CHAPTER III. 


Anatomical Lesions .... 867 


Art. I. — Lesions of the Thoracic Organs . 






. 


Sec. 1. — Lungs. 






. 


Sec. 2. — Heart and Blood 






867 


Art. II. — Lesions of the Cerebro-Spinal Apparati 


is 




368 


Sec. 1.— Brain and its Envelops 






368 


Art. III. — Lesions of the Abdominal Organs 






. 


Sec. 1. — Liver .... 






872 


Sec. 2.— Spleen 






877 


Sec. 3.— Stomach 






878 


Sec. 4. — Intestines 






880 


Art. IV. — General Remarks 








Sec. 1. — Relation of Lesions to Symptoms 






3 


Sec. 2. — Importance, Relative and Absolute 






384 


CHAPTER IV. 


Causes ....... 


Sec. 1. — Locality 








Sec. 2. — Season; Temperature: Weather 








Sec. 3. — Age .... 






390 


Sec. 4. — Sex .... 






391 


Sec. 5. — Race .... 






391 


Sec. 6. — Exposure ; Excesses, &c. 






392 


Sec. 7. — Malaria 






393 


CHAPTER V. 


Varieties and Forms ..... 397 


Art. I. — Bilious Remittent Form . 






397 


Art. II. — Congestive Fever 






398 


Sec. 1. — Names 






398 


Sec. 2. — Type, and Mode of Attack 






399 


Sec. 3. — Varieties ; Comatose . 






400 


Sec. 4. — Delirious Variety 






401 


Sec. 5. — Algid Variety 






402 


Sec. 6. — Gastro-Enteric Variety 






404 


Art. IJI. — Intermittent Fever 






406 


2* 









XX11 



Duration and March . 
Sec. 1. — Duration 
Sec. 2. — March 
Sec. 3. — Critical Days 
Sec. 4. — Eelapses 
Sec. 5. — Sequelae 



CONTENTS. 






CHAPTER VI. 




PAGE 


. 




408 


. 




408 


. 




408 


. 


* 


411 

411 


. 




411 


CHAPTER VIL 







Mortality and Prognosis 



415 



CHAPTER VIII. 



Diagnosis 



422 



CHAPTER IX. 



Theory . 



425 



CHAPTER X. 




Treatment ...... 


429 


Art. I. — Bilious Remittent Fever . 


429 


Sec. 1. — Preliminary .... 


429 


Sec. 2.— Bloodletting .... 


429 


Sec. 3. — Purgatives . . 


431 


Sec. 4. — Cinchona .... 


431 


Sec. 5. — Diaphoretics, Refrigerants, &c 


433 


Art. II. — Congestive Fever 


433 


Art. III. — Intermittent Fever . 


439 


CHAPTER XL 





Definition 



444 



CHAPTER XII. 



Bibliography . 



446 



CONTEXTS. 



XX111 



PART IV. 

YELLOW FEVER. 

CHAPTER I. 



Names of the Disease . 



T".r,E 

467 



CHAPTER II. 

Symptoms ..... 

Art. I. — Mode and Period of Access 
Art. II. — Febrile Symptoms 

Sec. L— Chills .... 

Sec. 2. — State of Surface : Sweats 

Sec. 3.— Pulse .... 
Art. III. — Digestive and Abdominal Symptoms 

Sec. 1. — Tongue and Mouth 

Sec. 2. — Appetite and Thirst . 

Sec. 3. — Nausea and Vomiting . 

Sec. 4. — Bowels ; Abdomen ; Epigastrium 

Sec. 5. — Urine .... 
Art. IV. — Cerebro-Spinal, or Nervous Symptoms 

Sec. 1. — Headache and other Local Pains 

Sec. 2.— State of Mind 

Sec. 3. — Physiognomy . 

Sec. 4. — Strength; Muscles; Senses . 
Art. V. — Miscellaneous Symptoms 

Sec. 1. — Color of Skin . 

Sec. 2. — Hemorrhages . 

Sec. 3.— Chest .... 



168 

460 
460 
4G0 
401 
464 
464 

466 
467 

469 

470 

471 

a:-. 

474 

474 
47.") 

47-". 



CHAPTER III. 

Anatomical Lesions .... 
Art. I. — Lesions of Lungs, Heart, and Blood 

Sec. 1. — Lungs 

Sec. 2.— Heart .... 

Sec. 3.— Blood .... 
Art. II. — Lesions of the Cerebro-Spinal Apparatus 
Art. III. — Lesions of the Abdominal Organs 

Sec. 1. — Stomach 

Sec. 2. — Intestines 

Sec. 3. — Liver .... 

Sec. 4. — Gall-Bladder and its Contents 

Sec. 5. — Spleen ; Mesenteric Glands ; Urinary Organs 



477 
477 
477 

478 
479 
480 
480 
480 
483 
484 
480 
491 



XXIV 



CONTENTS. 



Art. IV. — Miscellaneous Lesions . 
Art. V. — General Remarks 

Sec. 1. — Relation between Symptoms and Lesions 

Sec. 2. — Causes of Death 



PAGE 

491 
491 
491 
494 



CHAPTER IV. 



Causes 





495 


Sec. 1. — Locality ..... 


495 


Sec. 2.— Season 


499 


Sec. 3. — Temperature and Weather . 


500 


Sec. 4. — Age . ... 


502 


Sec. 5. — Sex . 


502 


Sec. 6.— Race ...... 


504 


Sec. 7. — Constitution . . . 


505 


Sec. 8.— Occupation . . . . N 


506 


Sec. 9.— Acclimation ..... 


506 


Sec. 10.— Exemption from Subsequent Attacks 


508 


Sec. 11. —Epidemic Influences .... 


510 


Sec. 12.— Sporadic ..... 


511 


Sec. 13.— Marsh Miasmata 


512 


Sec. 14.— Decaying Animal and Vegetable Matter 


513 


Sec. 15.— Contagion . . . . 


515 


Sec. 16.— Exposure; Fatigue; Excesses, &c. . 


524 


Sec. 17.— Essential Poison ..... 


526 



CHAPTER V. 



Varieties and Forms .. 

Sec. 1. — Season and Locality 
Sec. 2. — Forms, or Grades 



528 
528 
529 



CHAPTER 


VI. 




March and Duration . 




533 


Sec. 1. — March, or Type 






533 


Sec. 2. — Stages 






536 


Sec. 3.— Duration 






538 


Sec. 4. — Convalescence 






538 


Sec. 5. — -Relapses 




. 


540 


Sec. 6. — Sequelae 




. 


540 


Sec. 7.— Period of Incubation 




. 


540 


CHAPTJ 


3R 


VII. 





Mortality and Prognosis 



541 



CONTENTS. 



XXV 



CHAPTER VIII. 



Diagnosis 



PAGZ 

547 



CHAPTER IX. 



Theory 



550 



CHAPTER X. 








Treatment . . ' . 


Sec. 1. — Preliminary . 






552 


Sec. 2. — Mercurials 








Sec. 3. — Antiphlogistic Method 






666 


Sec. 4. — Cinchona ; Tonics and Stimulants 






558 


Sec. 5. — Purgatives 






568 


Sec. ('). — Spanish Method 






§68 


Sec. 7. — Mobile Method 








Sec. 8. — Prophylactics . 






660 


Sec. 9. — Conclusion 






-V,] 


CHAPTER XI. 









Definition 






CHAPTER XII. 



Bibliography 






PART FIRST. 



the 



HISTORY, DIAGNOSIS, AND TREATMENT 



OF 



TYPHOID FEVEK. 



TREATISE ON FEVERS 



PART I. 
TYPHOID FEYER. 



CHAPTER I. 

PRELIMINARY MATTERS. 

ARTICLE I. 
INTRODUCTORY. 

In writing a history of the fevers of the United States, I 
begin with that of Typhoid Fever, for three reasons. 

In the first place, my own knowledge of the disease, derived 
from personal observation, is much more extensive than of the 
other forms of fever. My attention was early and strongly called 
to its investigation by the remarkable work of Louis upon the 
same disease, as it shows itself in Paris. Many years of my 
professional life have been passed in the midst of a population 
especially exposed to some of its predisposing causes, and 
amongst whom it has very constantly, and at times very ex- 
tensively, prevailed ; so that a personal acquaintance with this 
fever, of twenty years' continuance, has given me sufficient 
opportunity to become somewhat familiar with its character ; 
more so, at any rate, than with the remaining diseases, which I 
propose to describe. 

In the second place, there is good reason to think that typhoid 

fever is more generally and extensively prevalent, in various 

parts of the world, than the other distinct forms of essential or 

idiopathic fever. This is a point which requires further and 

4 



50 TYPHOID FEVER. 

more accurate observation for its settlement ; but it is pretty 
certainly true of the temperate latitudes of Europe and America. 
The actual extent of its prevalence will be more fully spoken of 
hereafter. 

In the third place, typhoid fever has been more minutely, more 
accurately, more thoroughly studied, than any other distinct 
form of essential or idiopathic fever. Although a complex, and 
in many respects an obscure disease, its diagnosis is, in most 
cases, easily and positively made out. Its natural history has 
been very fully investigated, and the results of this investigation 
faithfully recorded and summed up. Its symptoms, its lesions, 
its causes, so far as these latter are appreciable, have been 
very exactly ascertained and settled ; and they have been very 
patiently compared with the symptoms, the lesions, and the 
causes of other diseases. This more complete knowledge of the 
disease renders it a very convenient starting-point, and an ex- 
ceedingly valuable standard of comparison, in our subsequent 
study of other forms of fever, more or less related to this, but 
whose history and character have not been so definitively and 
precisely established. These, very briefly, are the simple and 
obvious considerations which induce me to commence this history 
with a description of typhoid fever. 

ARTICLE II. 

NAMES OE THE DISEASE. 

I have adopted the term typhoid fever as the name of this dis- 
ease, simply because it is not particularly objectionable, and 
because it seems to be coming into general use. It is that which 
is most commonly given to the disease by the French, although 
many of their writers have coined other, and as they think, more 
appropriate appellations. Petit and Serres described it, in 1813, 
under the name of enter o-mesenteric fever. This term, as has 
been observed by Andral, has the advantage of marking the 
peculiar lesion of the disease, while it is free from the objection 
of prejudging, by any implication, its nature or character. 
Bretonneau calls it a dothinenterite, from the pustular inflamma- 
tion of the intestine. Cruveilhier and others have applied to it 
the name of follicular enteritis. Bouillaud has called it typhoid- 



NAMES OF THE DISEASE. 51 

entero-mesenteritis. By the Germans it is commonly called 
abdominal typhus. By some German writers it is called nervous 
fever, or gastric nervous fever ; by some it is called intestinal 
ulcerating typhus, or typhous suppuration of the intestines ; by 
others, typhus gangliar is, and so on. 1 In New England, it has 
generally been known under the name of typhus, or typhous 
fever ; and by many practitioners it still continues to be so desig- 
nated. Since, however, it has been ascertained that the die 
differs, in many important respects, from the ty pints- of British 
writers, it has become manifestly necessary to apply to it some 
other appellation; and, in conformity to the example of Louis, 
Gerhard, Jackson, and others, I have chosen that of typhoid 
fever. 

It may be well to say a word here in regard to the identity of 
the continued fever of New England with the typhoid fever of 
the French pathologists. This identity is very clearly and posi- 
tively settled. No one familiar with the dis< it >ho\v< 
itself in Paris, and as it is described by Louis, ('home], and 
Andral, and who reads Nathan Smith's description of the typhous 
fever of New England, can doubt for a moment, so far as the 
symptomatology is concerned, that such is the case. The identity 
of the pathological lesions in the fever of the two countries has 
been more recently established. Dr. E. Bale, Jr., of Boston, 
published in the Medical Magazine for December, 1833, an 
account of three dissections of persons, considered by him to 
have died with this disease. If the diagnosis in these cases 
could be looked upon as certain and positive, they would consti- 
tute, so far as I know, the first published examples of the intes- 
tinal lesion of the disease, as it occurs in New England. The 
diagnosis, however, in all the instances, must be regarded as 
somewhat doubtful, and the alteration of the intestinal follicles 
does not seem to have been very clearly or strongly marked. 
The first authentic and unequivocal cases on record, that I have 
been able to find, are two, which were published by Dr. Gerhard, 
in the American Journal of Medical Sciences for February, 
1835. In the Medical 3Iagazine for June, 1835, 1 gave a short 
account of the entero-mesenteric alterations in five cases of 
unequivocal typhoid fever, which alterations corresponded ex- 

1 Edin. Med. and Surg. Journ., vol. xlviii. p. 145. 



/ 



52 TYPHOID FEVER. 

actly to those described by Louis. I have upon my note-book 
the anatomical history of two similar cases, which occurred during 
the months of January and February, 1833, but which were 
never published. Dr. James Jackson, Jr., then a medical student, 
observed the intestinal lesion in a clear case of the disease as early 
as October, 1830, although the account of the observation was not 
made public till 1835. 1 Dr. Jackson, Jr., after having studied 
typhoid fever in Paris, aided and guided by the personal instruc- 
tions of Louis, again saw the disease in Boston ; and in two cases, 
one of which occurred in 1833, and the other in 1834, he found 
the characteristic lesion of the intestinal follicles and mesenteric 
glands. An account of these observations was published in 
1835. Dr. Jackson, Sen., in his Report on Typhoid Fever, 
communicated to the Massachusetts Medical Society in June, 
1838, says, that the alteration of Peyer's glands had been noticed 
at the Massachusetts General Hospital, previous to 1833, in cases 
which were carefully examined. Since the period above referred 
to, more extensive and accurate observations by Dr. J. Jackson, 
Dr. Hale, Dr. Bigelow, Dr. Bowditch, Dr. J. B. S. Jackson, 
Dr. Shattuck, Jr., Dr. Holmes, and others of Boston ; and by 
Dr. Gerhard and Dr. Stewardson of Philadelphia, Dr. Swett of 
New York, and others, have uniformly sustained the correctness 
of these early conclusions, and demonstrated the entire identity 
of the typhoid fever of Paris and of the United States. 

ARTICLE III. 

HISTORY. 

By the history of typhoid fever> here, I mean what may be 
called its literary history — an account of the successive investi- 
gations which have led to our actual knowledge of the disease. 
In order to render this at all full and complete, it would be 
necessary to go into the history of the entire subject of continued 
fever, a subject more extensive and more complicated perhaps 
than any other in the domain of medical science. Neither the 
design nor the character of my book renders it necessary that I 
should do this ; I shall content myself with touching simply a 
few of the more salient points of this history. 

1 Memoir of James Jackson, Jr., p. 222, et seq. 



HISTORY. 59 

The character of typhoid fever — its symptoms, its lesions, its 
causes, and so on — was first fully and carefully studied by the 
physicians of the continent of Europe. The first description of 
its pathological lesions, at all complete and satisfactory, was con- 
tained in the work of Prost, published in 1804. Some years 
subsequent to this, Broussais succeeded in establishing his bril- 
liant and powerful but transitory dynasty, and under its tyran- 
nous domination, the study of continued fever, on the continent, 
was cramped and misdirected, instead of being properly guided, 
favored, and advanced. Everything gave way to the bold effron- 
tery of the dogma, that all fevers are dependent upon focal in- 
flammations. In looking back now upon the career and aeli: 
ments of Broussais, it is astonishing to see with what meek 
alacrity our science put on and wore the yoke which he fitted to 
her neck. The exclusive and hypothetical views of Brora 
were controverted ably, and at length successfully by Andral, 
Chomcl, and other pathologists; but it is to the great work of 
Louis that we are indebted for the first complete and compre- 
hensive description of typhoid fever — a description s<> complete, 
and so comprehensive, that the labors of subsequent observers 
have hardly added to its materials, or modified its proportions to 
any appreciable extent. Amongst other continental observers 
wdio studied particularly the intestinal lesions of the di> 
were Rcederer and Wagler, Petit and Serres. and Bretonneau. 
The original researches of Louis and Ohomel were confined to 
the disease as it shows itself in the adult; within the last few 
years the typhoid fever of children has been carefully studied, 
especially by Barthez and Rilliet, and by Taupin. Dr. Richard 
Bright has given, amongst his very splendid pathological illus- 
trations, some excellent specimens of the intestinal ulcerations of 
this disease. The important and valuable papers of Dr. Jenner, 
of London, have already been referred to. The most important 
publications upon the subject made in this country are those of 
Nathan Smith, Dr. James Jackson, and Dr. E. Hale, of Boston, 
and Dr. W. W. Gerhard, of Philadelphia. 



54 TYPHOID FEVER. 

ARTICLE IV. 

METHODS OF DESCRIPTION. 

There are two methods, either of which may be adopted, in 
the description of a disease. One of these, and that which, 
with a few exceptions, has been in universal use from the time of 
Hippocrates to the era of Louis, consists in a general enumera- 
tion of the more striking and obvious phenomena of the disease, 
in their various combinations and progress, constituting a kind of 
portrait, or picture. The other, which has been followed by 
many writers within the last fifteen years, especially amongst 
the French, consists, not merely in this general enumeration of 
the phenomena, their combinations and progress, but in a tho- 
rough and careful analysis of these phenomena ; in a special 
and particular study of each individual element, which goes to 
make up the disease ; and in a strict estimate of the relative 
value and importance of each and all of these several elements. 
This analytical process, this "searching operation," is applied in 
study, as well as in description, not only to the symptoms of a 
disease, but, to a * considerable extent, also, to its pathology, 
etiology, and therapeutics. Amongst the best examples of the 
first method, — the physiognomical portraiture of disease, — may 
be mentioned Sydenham's description of measles and St. Vitus's 
dance, and Dr. Ware's description of delirium tremens. The 
first and one of the most perfect examples of the latter is to be 
found in Louis's Researches upon Phthisis, published in 1825. 

Each of these methods has its advantages and its disadvan- 
tages, its excellences and its defects. By the first, a more com- 
plete and integral picture of the disease is presented at once, to 
the mind, than can be done by the second. We are enabled to 
see, at a single glance, the form, the outlines, the features, the 
physiognomy of the disease. But in many very important par- 
ticulars, this method is inferior to the second. It is merely a 
picture of disease ; like all other pictures, more or less like the 
original, strongly or feebly colored, according to the peculiar 
taste or ability of the individual artist. It is necessarily wanting 
in the scientific accuracy of which the second is susceptible. It 
is less complete, less perfect. The disadvantages of the latter 
consist in the absence of that wholeness and unity of impression, 



METHODS OF DESCRIPTION. 55 

which are made by the former. The mind, in order to get at the 
integral and entire picture, must arrange and combine the scat- 
tered materials, which it has studied separately. As one of the 
leading purposes of the present work is to point out, as far as our 
actual knowledge will enable us to do so, the characteristic 
features of each of the four great forms of idiopathic fever ; to 
establish, as far as possible, a clear and positive diagnosis ; to 
ascertain the resemblances and the differences between them ; I 
shall rely almost exclusively upon the last-mentioned method, as 
the only one capable of leading to these results. 



56 



CHAPTER II. 

SYMPTOMS. 

ARTICLE I. 

MODE OF ACCESS. 

There is a good deal of difference, in different cases of typhoid 
fever, so far as the suddenness or violence of the seizure is con- 
cerned. There is no other acute disease, perhaps, in which the 
attack is more frequently slow and gradual than in this. In 
many cases, it is quite impossible for the patient to fix with any 
accuracy upon the day when his fever commenced. Neither, in 
many of these same cases, is he able to tell in what his sickness 
consisted. He can only say that, for several days, he has not 
enjoyed his accustomed degree of health. He may have merely 
felt a sensation of mental and bodily languor, an indisposition, 
or an inability to accomplish his usual labor, either of mind or 
body. He may have had slight and dull pain in the head, or in 
the back and limbs, with a general feeling of soreness or of fatigue. 
At the same time he may have experienced some sensations of 
chilliness, alternating with heat. There may have been, also, 
diminution or loss of appetite, and moderate thirst, with a dry 
or clammy state of the mouth. The expression of the counte- 
nance sometimes becomes listless and dull, the eye loses its 
animation, and the mind is either indifferent or apprehensive. 
There may have been moderate diarrhoea, with" some pains in the 
abdomen. This obscure and indefinite condition of ill health 
may continue for more than a week, occasionally for two or three 
weeks even, with but slight changes from day to day. Oftentimes 
there is a slow but steady increase in the severity of these morbid 
sensations, with a like gradual but regular appearance of other 
and more characteristic symptoms of the disease — these latter 
coming out, day by day, one after another, a complete and sue- 



MODE OF ACC 57 

cessive development of the peculiar and strongly marked pheno- 
mena of the disease. In other cases, after an indefinite conti- 
nuance of this obscure precursory period, there is a sudden 
supervention of the more violent symptoms. Nathan Smith says : 
"The disease attacks in such a gradual manner, that we hardly 
know on what day to fix its commencement." 1 Dr. James Jack- 
son says: " There is more difficulty, perhaps, in ascertaining the 
commencement in cases of typhoid fever, than in many other 
acute diseases." 2 

In a certain proportion of cases, however, precisely how large, 
I am not able to say, the access of the fever is more violent, and 
its period much more distinctly marked. Chomel, indeed, says, 
that most frequently the invasion is sudden, coming on in the 
midst of perfect health, unexpectedly, and not preceded by any 
precursory symptoms. Of one hundred and twelve cases, in 
which this point was exactly observed, the acce idden in 

seventy-three; in the others, there were obscure premonitory 
symptoms. 3 Forget thinks the gradual access of the diseac 
more common than is indicated by these statistics, and this 
opinion agrees with my own observation. I am sure that, in a 
large proportion of cases, in private practice, tin- dif ^low 

and gradual in its approaches. It will he at once seen that this 
question can lie more readily settled in private than in hospital 
practice. The mode of attack, in these Cases, is various; most 
frequently, perhaps, by a chill, accompanied by debility ami 
headache, and followed by heat and thirst. In other cases, the 
mode of attack is different. During a grave epidemic of typhoid 
fever, which prevailed in the city of Lowell, in the winter of 
1834-5, I saw two cases, in which the first feelings of ill health, 
experienced by the patients, so far as could be ascertained from 
them, consisted of severe, griping pains in the bowels, accompa- 
nied with tenderness on pressure. In these cases, diarrhoea was 
an early and prominent symptom. In another, and that a fatal 
case, the patient had been at her usual work during the day, and 
on getting into bed at night felt lame, this being the first feeling 
of sickness of which she w T as conscious. The mode of attack 
was ascertained in seventeen fatal cases by Dr. Jenner. " In 

1 A Practical Essay on Typhus Fever. By Nathan Smith, M. D. 

2 Report on the Typhoid Fever. By James Jackson, M. D. 

3 Le§ons cle Clinique Medicale, Chomel, p. 4. 



58 TYPHOID FEVER. 

seven of these, the disease began so suddenly that the exact day 
of its commencement could be ascertained ; six out of the seven 
took to their beds respectively on the 1st, 1st, 2d, 3d, 10th, and 
16th days; the last two patients, however, were obliged to lie down 
part of the day from an early period in the disease. No' note 
was taken of the time when the seventh first kept his bed. In 
the remaining ten of the seventeen cases, the disease began 
gradually. Of these, four were ailing for a few days, and then 
became suddenly worse ; three of the four took to their beds 
respectively on about the 7th, 8th, and 11th days of the disease. 
The other six of the ten, in whom the disease began insidiously, 
could fix on no particular day as that on which their illness began, 
but only stated that they became gradually ill from about a given 
day ; of these, four took to bed severally on about the 3d, 7th, 
12th, and 17th days of the disease ; when the others first kept 
their bed was uncertain. So that only 28.5 per cent, took to 
bed before the seventh day." 1 But, whatever be the mode of 
attack, whether this be slow, insidious, creeping and obscure, 
marked by no obvious and prominent symptoms, or, on the 
other hand, sudden and violent — in either case, the disease 
goes on, for a considerable period of time, varying of course 
according to its severity, and its favorable or fatal termination ; 
during which progress, it is characterized by a greater number 
and variety of symptoms — in themselves, in their combinations, 
and their successive appearance, peculiar to this fever, than are 
to be found in any other form of acute disease. These several 
symptoms, classified and arranged, I now proceed to describe, as 
fully and faithfully as the present state of our knowledge will 
enable me to do. 



ARTICLE II. 

FEBRILE SYMPTOMS. 

Sec. I. — OJiills. Like most acute diseases, typhoid fever is 
attended by chills or rigors. These are, generally, not very 
severe. Dr. Jackson says, that in the Massachusetts General 
Hospital, rigors were much less frequent than chills. Nathan 

1 Jenner on the Identity or Non-identity of Typhoid and Typhus Fevers, p. 7. 



SYMPTOMS. — CHILLS. — STATE OF SKIN. 59 

Smith observes, merely, that in the commencement there is, 
generally, some degree of chilliness felt by the patient. Of 
thirty-three fatal cases, cited by Louis, thirty-one had chills ; in 
one-fourth of which number they were severe, accompanied with 
trembling. Of forty-five grave cases, recovered, all were mark- 
ed by chills, excepting three ; and of thirty-one mild cases, there 
were chills in twenty-four. 

This symptom, in a great majority of instances, is present at 
the commencement, or very early in the disease. It is one of 
the most constant attendants upon the formal access of the fever. 
The chill occurs oftenest in the course of the day, and in a large 
proportion of cases is repeated more or less frequently during 
the early period of the disease. It is not less constantly present 
in cases amongst children, than it is amongst adults. 

Sec. II. — Heat and State of the Skin. Following the chill or 
rigor, and in the intervals, when these are repeated, there is 
almost always increased heat of the skin. This heat varies very 
much in different respects. In many patients, it is quite mode- 
rate in degree, and pretty uniformly diffused over the body. In 
others, the morbid heat is high and burning, and not unfrequently 
very unequally distributed. Nathan Smith says: "Sometimes, 
the head and trunk will be excessively hot, while the extremities 
are cooler than natural; at others, the extremities will be preter- 
naturally hot, when the body is but moderately so. One cheek 
will often appear of a deep red color and be very hot, while the 
other remains pale and cool ; as its color and heat subside, they 
seem to cross over and affect the opposite cheek in the same 
manner. This color and heat usually extend so far as to include 
the ear of the affected side." Dr. Jenner says: "The natural 
hue of the face — i. e., of the skin of the whole face — was un- 
changed, excepting in three cases, in which it had a very slightly 
marked dusky appearance. There was no flush in three, and no 
note made of its presence in eight cases. In twelve of the twenty- 
three cases the face was flushed ; in eleven of the twelve the 
flush was pink, and limited to one or both cheeks ; it varied in 
intensity, disappeared, and returned occasionally, in the same day. 

" This limitation of the flush to the cheeks was not peculiar 
to any one period of the disease ; it was well marked in one case, 
when admitted on the eighth day of the disease, and continued 



60 TYPHOID FEVER. 

so till the twenty-third day, the patient dying on the twenty-fifth. 
In another, admitted on the fifth day, there was a circumscribed 
flush on the cheeks, on the seventh day, which continued with 
little change till the fifteenth day, the patient dying on the 
seventeenth day. 

" This flush when conjoined, as it sometimes was, with extreme 
emaciation, sunken eyes, large pupils, quick breathing, sharp and 
somewhat anxious manner, forcibly recalled to the mind cases, 
not of typhus fever, but of phthisis." 1 In the latter stage of 
grave and fatal cases, the intensity of the morbid heat frequently 
diminishes ; and in mild cases, it is not often very high, even in 
their early periods. 

This morbid heat, as one of the elements of the exacerbations, 
or fever fits, is subject to certain variations in the course^ of each 
day. In grave cases, these are of very constant daily occur- 
rence. Sometimes they are irregular in their appearance, 
coming on at different and uncertain times of the day, although 
more commonly there are two each day. In the early period of 
the disease, the most strongly marked exacerbation is usually in 
the afternoon. During these fever fits, there is increased red- 
ness of the cheeks, acceleration of the pulse, and a general 
aggravation of the severity of all the uncomfortable and painful 
sensations. Dr. Jackson remarks, that these exacerbations are 
much more common in some years than in others. 2 

The state of the skin, in regard to dryness and moisture, is 
quite different in different patients. In a small proportion of 
severe cases, the skin is almost constantly dry, during the whole 
course of the fever. In others, there is more or less moisture. 
Sometimes the sweats are limited to a short period following the 
evening exacerbation, or they break out in the night, during sleep. 
Not unfrequently they are profuse, sometimes confined to certain 
portions of the body, at others extending over the whole surface. 
Chomel says that they often exhibit a strong acid odor. Louis 
observes, that the sweats are in no degree proportionate to the 
morbid heat, and that not unfrequently they are prolonged 
during convalescence, preventing the re-establishment of the 
strength, and resisting the influence of aromatics and bitters. 
Nathan Smith speaks of "what has been called the washer- 

1 Jenner, &c. p. 20. 

2 Report, &c. p. 135. 



SYMPTOMS. — PULSE. 61 

woman 8 sweat, which is extremely profuse over the whole surface 
of the body and extremities ; standing in large drops on the face, 
and giving to the cuticle, on the palms of the hands and soles of 
the feet, a corrugated appearance and a light color, as if it had 
been long macerated in water. In such cases, the perspiration is 
warm, till a short time before the patient expires." He never 
saw an instance of recovery after this kind of sweating. 

Dr. Smith says, also: "There is a remarkable odor arising 
from a person affected by this disease, so peculiar that I feel 
assured that upon entering a room, blindfolded, where a person 
had been confined for some length of time, I should be able to 
distinguish it from all other febrile affections." My own expe- 
rience, in this matter, coincides with that of Dr. Smith. This 
odor, which is not pungent and ammoniacal, like that which is 
said to arise from the bodies of patients with the grave forms of 
the British typhus, but of a semi-cadaverous and musty character, 
I have frequently noticed, especially during the late stages of 
severe and fatal cases. 

After recovery, when the case has been one of considerable 
severity, the cuticle often peels off, in large flakes, from the 
palms of the hands and the soles of the feet ; the hair, also, 
frequently falls off from the head, and is succeeded by a new 
growth. 1 

Sec. III. — Pulse. The circulation is nearly always accele- 
rated; and, in many cases, otherwise modified. The frequency 
of the pulse, during the whole course of the disease, may be said 
to range between 70 and 140 in the minute. As a general rule, 
the frequency of the pulse is in proportion to the severity and 
danger of the disease. The pulse is considerably more frequent 
in female, than in male patients. Dr. Jackson's Report contains 
some interesting results in regard to this subject. He found, 
that in the cases which terminated favorably, the average, least 
frequent pulse was 74.16, and the average, most frequent pulse, 
102.68; while in the cases which terminated fatally, the average, 
least frequent pulse was 91.88, and the average, most frequent 
pulse was 129.29. Amongst the fatal cases, in the males, the 
average, least frequent pulse was 85.50, the average, most frequent 
pulse, 124.29 ; while amongst the fatal cases, in the females, the 

1 Xathan Smith. On Typhous Fever. 



62 TYPHOID FEVER. 

average, least frequent pulse was 106.64, and the average, most 
frequent pulse, 138.58. With the establishment of convalescence, 
the pulse, generally, though not always, approaches its healthy 
standard of frequency. 

The other variations in the character of the pulse are not sus- 
ceptible of such definite statement, as those of its frequency, but 
they are still, in many cases, very obvious. Sometimes, especially 
in mild cases, where the circulation is only moderately accelerated, 
the pulse preserves its natural softness and volume. This is 
never the case where it is very frequent. The pulse is then some- 
times sharp and jerky, generally small, and pretty easily com- 
pressed, and not unfrequently, undulating, or bis-feriens. 

Distinct intermissions and irregularity of the pulse are not very 
common, although they occur in a moderate proportion Nof very 
grave and fatal cases. Louis thinks that this modification of the 
pulse is generally connected with a secondary affection of the 
heart. 



ARTICLE III. 

THORACIC SYMPTOMS. 

Sec. I. — Respiration. Modifications in the character of the 
respiration are not often mentioned amongst the phenomena of 
typhoid fever ; but they are of pretty frequent occurrence, and 
some of them are deserving of particular notice. The most com- 
mon alteration of the breathing consists simply in the usual ac- 
celeration, which accompanies febrile excitement. Under certain 
circumstances, however, there is a more marked and peculiar 
change in the character of the breathing. In high grades of the 
disease, and particularly in its later stages, accompanied inva- 
riably or nearly so by delirium or stupor, the respiration becomes 
irregular, noisy, and hissing. Nathan Smith speaks particularly 
of this peculiarity of the breathing. He says: "After the 
patient has been some time sick, if the disease proves severe, 
there is a peculiar whistling sound produced when he breathes 
through the nose ; and when asleep, or lying in a state of coma, 
the mouth is generally kept open, and the breathing has some- 
what of a stertorous sound." I do not think that this irregular, 
noisy, sibilant respiration depends, in any degree, upon disease 



SYMPTOMS. — RESPIRATION. — COUGH. — PHYSICAL SIGNS. 63 

of the lungs. It is manifestly connected with and dependent 
upon a morbid condition of the brain. 

Positive dyspnoea is not very common. It occurs where there 
is extensive secondary disease of the lungs, and sometimes it is 
occasioned by excessive tympanitic distension of the abdominal 
parietes. 

Sec. II. — Cough. Typhoid fever, in a large majority of cases, 
is attended by cough. This is generally slight, and hardly at- 
tracts the attention of the physician or the patient. According 
to Louis, it most commonly commences between the fifth and the 
fifteenth day of the disease. The sputa are usually small in 
quantity, sometimes tenacious and colorless, sometimes bloody, 
simply from an admixture with blood from the nares, and some- 
times rusty from a complication of pneumonitis. 

Sec. III. — Physical Signs. The most constant and character- 
istic of the physical signs, connected with the thoracic organs, 
consists in a dry, sonorous, or sibilant rhonchus. This, in many 
cases, is very loud, and heard universally over the chest ; its ex- 
tent and severity altogether disproportionate to the dyspnoea. 
Louis was the first, I think, who noticed, particularly, this sign 
in typhoid fever. It appears early in the disease. Late in the 
fever, especially near the close of cases about to terminate fatally, 
there is often a circumscribed crepitous rhonchus, with other phy- 
sical signs of local, secondary pneumonitis. Occasionally, instead 
of the dry, sonorous or sibilant, there is a humid or mucous 
rhonchus. In many of the grave and fatal cases, there is some 
dulness on percussion over the most dependent portion of the 
chest. 



ARTICLE IV. 

CEREBRO-SPINAL, OR NERVOUS SYMPTOMS. 

Having completed the detail of symptoms, to which the term 
febrile is more particularly applied, and which, with certain mo- 
difications and peculiarities, are common to all essential fevers, to 
all acute inflammatory diseases of considerable extent or severity, 
and to very many chronic organic alterations, I now proceed to 



64 TYPHOID FEVER. 

the description of another very extensive group of phenomena, 
consisting in disturbances of the functions of the nervous appara- 
tus. These disturbances occupy a very important place in the 
natural history of typhoid fever, and serve, to a very considerable 
degree, to distinguish it from nearly all other forms of disease. 

Sec. I. — Headache. Pain in the head is amongst the most 
constant symptoms of the disease. It is, indeed, very rarely 
absent. Louis says, that of eighty-seven cases, in which the pa- 
tients recovered, there was headache in all but three. It is as 
common an accompaniment of mild as it is of severe cases. 

This pain is amongst the earliest symptoms. In many cases, 
it is the first thing which arrests the attention of the patient, and 
marks the formal access of the fever. Chomel says, that this 
occurs most frequently on rising in the morning. Sometimes it 
comes on after the third or fourth day. Its duration is various ; 
but, very generally, after a longer or shorter period, it gradually 
diminishes in severity and finally disappears. In severe cases 
which recovered, Louis found its most common duration to be 
from eight to ten days. 

The character and degree of this pain are various. Most fre- 
quently, it is dull, heavy, or throbbing, not occupying very much 
the attention of the patient. In a few cases, it is intense and 
acute, occasioning great distress. It is generally continuous, al- 
though its severity may be increased during the febrile exacer- 
bations. It is less severe in mild, than in grave cases. Now 
and then, it is the most prominent and importunate symptom 
during the whole course of the disease. It occupies, most fre- 
quently, perhaps, the forehead and temples, but it often extends 
over the whole head. It is not unfrequently accompanied with 
some soreness and stiffness of the eyeballs, felt on pressure and 
on motion. 

This symptom is generally present in children. Taupin says 
that the pain is almost always confined to the frontal region. It 
is heavy, and not very acute. 

Sec. II. — Pains in the bach and limbs. In many cases, the 
headache is attended with pains in the back and limbs. These 
pains, I think, are more constant and distressing in the legs than 



SYMPTOMS. — STATE OF THE MIND. 65 

in the arms. They go off with the headache, and frequently, 
indeed, before the disappearance of the latter. 

Sec. III. — State of the Mind. I have already remarked, in 
speaking of the mode of access of typhoid fever, that one of the 
earliest and most constant phenomena consists in mental languor 
or inability. The patient is sometimes impatient and irritable, 
but more frequently listless and indifferent, or perhaps timid, 
and apprehensive of the danger of the approaching disease. He 
finds it difficult to fix his attention, or to pursue his accustomed 
train of thought. He is forgetful, and does not measure the lapse 
of time with his usual readiness and accuracy. This condition of 
the mind, in cases of moderate severity, may continue through 
the entire course of the fever, up to the period of convalescence. 
In graver and fatal cases, it is generally lost either in delirium or 
stupor. 

Delirium is a common symptom of typhoid fever. Its fre- 
quency and degree are in pretty direct proportion to the severity 
and danger of the disease. Of forty-six fatal cases, cited by 
Louis, there was delirium in thirty-eight. In two of these, the 
delirium was of short duration ; and in two others, it was present 
only during the last two or three days of life. But it should 
also be remarked, that seven of these cases were fatal from per- 
foration of the intestine ; and that this accident most frequently 
occurs in cases of moderate severity. I have seen the disease, 
in its worst form, terminating fatally in the course of the second 
week, without any delirium, but this is certainly not a common 
occurrence. Of Louis's fifty-six grave cases, terminating favor- 
ably, thirty-nine were marked by delirium; while of thirty-one 
mild cases, there was delirium in only three ; and even in these 
few, it was mild in its character and of short duration. 

In a small number of cases, this symptom is present at the 
commencement, or very early in the disease. Generally, how- 
ever, it comes on in the course of the first or second week of the 
fever. As a general rule, it appears early in proportion to the 
gravity and to the rapid progress of the disease. Its march and 
duration are various. In fatal cases, it rarely disappears, after 
its occurrence, till it is lost either in coma or death. In grave 
cases, which recover, it goes off with the approach or commence- 
ment of convalescence, its subsidence or diminution constituting 



66 TYPHOID FEVER. 

one of the earliest and surest signs of this desirable event. In 
many cases, especially of a mild or moderate character, and for 
the first few days after its appearance, even in severe cases, it is 
present only during the night, or in the febrile paroxysm, or, 
perhaps, for a transient period immediately after waking. Under 
such circumstances, the patient can be called back from his inco- 
herent wanderings, and, by exciting and holding the attention, 
his mind kept steady and clear. As soon, however, as this 
external excitement is withdrawn, the mind at once lapses into its 
disturbed and irregular action. 

The delirium is generally of the kind to which the terms low 
and muttering have been applied. In many cases, however, and 
especially in such as are rapid in their march, and of great 
severity, the delirium is attended with wild and violent agitation. 
Sometimes, the patient is in constant and restless motion in his 
bed, picking at his bedclothes, or pulling them about, and fre- 
quently drawing them tightly over his head. Sometimes, he 
rises suddenly from his bed, when, if not restrained, he will sit 
upon its side, or wander, aimless and incoherent, for a few 
moments, about the room. In these cases, the agitation is so 
violent, that it requires the constant presence of attendants, and 
occasionally no slight degree of force, to keep the patient in his 
bed. This violent delirium is often attended, also, with cries and 
screams, particularly during the night. Of Dr. Jenner's twenty- 
three fatal cases, "there was no delirium in three, but in one 
of the three there was considerable mental confusion. Delirium 
was present in twenty cases ; in ten of the twenty, it began seve- 
rally on the third, sixth, sixth, tenth, fourteenth, fifteenth, twenty- 
third, twenty-sixth, twenty-eighth, and twenty-ninth days ; seven 
were delirious, when first seen, between the thirteenth and twenty- 
first days inclusive ; in the remaining three of the twenty cases, 
it was uncertain at what date of the disease the delirium set in. 
The delirium continued till death in nine cases ; in eight of these, 
the fatal termination occurred on the twelfth, seventeenth, seven- 
teenth, twenty-first, twenty-fifth, twenty-seventh, thirtieth, and 
thirtieth day of the disease ; in one of the nine, the duration of 
the disease at the time of the patient's death was unknown. In 
one case, which proved fatal on the twenty-third day, there was 
no delirium after the twenty-first day, from which time till her 
death the patient lay in a state of profound stupor. The delirium 



SYMPTOMS. — STATE OF THE MIND. 67 

usually first showed itself at night, the patients sleeping during 
part of the day. It varied much in amount, sometimes being so 
violent that the patients left their beds, and even ran screaming 
through the wards ; at others, showing itself by slight delusions, 
only discovered to exist by accident, or again by almost constant 
chattering. Ten of eighteen patients, i. e. more than one half, 
or in the proportion of 55.5 per cent, of those who were delirious 
after they entered the hospital, and of whom notes on the point 
were made, left their beds to wander about the ward." 1 

Distinctly monomaniacal delirium is very rare, although it is 
seen occasionally, after the active period of the disease has gone 
by. Louis alludes to some cases, where, in the midst of the most 
dangerous symptoms, the patients declared, that they were very 
well. He says, that he has never known a patient, under such 
circumstances, to recover. The restoration of the healthy action 
of the mind, on recovery, is more or less gradual, but nearly al- 
ways complete. Nathan Smith says, that in some instances it 
appeared to him that the moral principle was affected after re- 
covery. He speaks particularly of a young man, who, after 
recovery from a grave form of the disease, had a strong propen- 
sity to steal. After repeated thefts, some of them from a young 
man to whom he was under great obligations, and who had nursed 
him during his sickness, he was detected and punished. His 
character before his illness had been good. Dr. Smith says, also, 
that, after recovery, the whole time that has elapsed, and all the 
events that have taken place during the fever, are entirely blotted 
out from the memory, and are never after recovered. This may 
be true to a certain extent, but not without many exceptions and 
qualifications. Louis says, in bis second edition, that, since the 
publication of his Researches, he has seen three hundred cases of 
typhoid fever, and that in only one was there any morbid condi- 
tion of the mind remaining after the establishment of convales- 
cence. Dr. Jenner says : " A remarkable fatuity remains, in some 
cases, long after recovery; and, in the majority of cases, I think 
there is some diminution of intellectual power for some little 
while after convalescence is established. I have seen many cases 
in which a childishness of mind remained for more than a month 
after, in other respects, restoration to health." According to 

1 Jenner, &c, p. 22. 



68 TYPHOID FEVER. 

Rilliet, delirium rarely shows itself in children before the fifteenth 
day of the disease. 

Sec. IV. — Physiognomy. The expression of the countenance 
is strongly marked and peculiar. Very generally, even in cases 
of moderate severity, it is dull, listless, and vacant. The eye is 
heavy and languid. The indifference, sluggishness, and apathy 
of the mind are strongly painted on the face. If there is much 
suffering, either from pain, or, as more commonly happens, from 
the indefinite and indescribable restlessness of fever, the usual 
heavy and stupid expression of the countenance is mixed with or 
supplanted by one of sadness, anxiety,, and distress. In many 
very mild cases, there can hardly be said to be any other change 
in the look, than a notable diminution of its animation an4 quick- 
ness. 

Sec. V. — Somnolence. In most cases, preceding the delirium, 
and often alternating with it after its appearance, there is more 
or less drowsiness or stupor. This symptom makes its appear- 
ance early in proportion to the intensity and to the rapid march 
of the disease, Louis found it present in nine-tenths of his fatal 
cases. When the fever was of a mild character, he noticed it in 
a little more than half the cases, and in these, it was later in its 
access, slight in degree, and brief in its continuance. In fatal 
cases, it generally persists and increases, after its first appearance, 
unless when interrupted by violent delirium, until it ends in com- 
plete coma, or is lost in death. Where the fever terminates 
favorably, it gradually subsides, and, like the delirium, finally 
disappears with convalescence. 

Dr. Jackson found that, in the Massachusetts General Hospital, 
it occurred in 1 case in 3.81, amongst those which terminated 
fatally, and in one case in 7.25, only, amongst those which ter- 
minated favorably. 

Sec. VI. — Vigilance. There is an opposite condition, that of 
prolonged and obstinate watchfulness, which is common in typhoid 
fever. This distressing symptom, interrupted perhaps occasion- 
ally by a transient, disturbed, and unrefreshing slumber, is more 
common in the early than in the late periods of the disease, and 



SYMPTOMS. — STATE OF THE SENSES. — MUSCLES. 69 

is much more frequently present in grave than in mild cases. It 
is often associated with restlessness or delirium. 

Sec. VII. — State of the Senses. Amongst the alterations in 
the functions of the senses, the most common are dizziness, ring- 
ing in the ears, and dulness of hearing. The first of these is 
often felt amongst the precursory symptoms, before the patient 
has taken to his bed, and it occurs subsequently, especially on his 
attempting to assume an upright position. Ringing or buzzing 
sounds in the ears are present, mostly in the early or middle 
period of the disease, in a majority of severe cases. In mild 
cases, they also occur, but less frequently. Dulness of hearing 
was noticed by Louis in two-thirds of his fatal cases, and in 
thirty-three of forty-five grave cases, terminating in recovery. 
It is somewhat less common where the fever is moderate. It 
appears earlier than the tinnitus aurium, and is not unfrequently 
followed by this latter sensation. Nathan Smith says, in his 
description of the disease : "The hearing is often impaired, almost 
from the commencement of the attack. Sometimes, false hear- 
ing occurs, and the patient imagines he perceives voices and 
sounds when nothing of the kind exists." 

The eyes and their functions are more rarely affected. If 
there is active febrile excitement, there is often increased sensi- 
bility to light, mostly in the early stage of the disease. Active 
injection of the conjunctivae is not often seen. 

Imperfect and perverted vision occurs occasionally, but it is 
not common. Like the dizziness and ringing in the ears, this 
not unfrequently comes on, temporarily, when the patient sits up 
in his bed. 

The sense of taste, as might be expected from the state of the 
tongue, and the loss of appetite, is either dull or perverted. 
Chomel speaks of patients who chewed, without repugnance, pills 
composed of medicinal substances, which were very disagreeable 
during health. 

The general cutaneous sensibility is not often affected, to any 
considerable extent. The feeling of soreness, occurring in the 
access of the disease, which has already been mentioned, appears 
to have its seat rather in the muscles than in the skin. 

Sec. VIII. — State of the 3Iuscles. Irregular spasmodic con- 



70 TYPHOID FEVER. 

tractions, or permanent rigidity of certain muscles, occur in a 
moderate proportion of cases of typhoid fever. The most com- 
mon are those of the fingers and wrist, to which the term subsultus 
tendinum has been applied. Sometimes they affect the muscles 
of the face, or that of the diaphragm, occasioning hiccough. 
Wherever they are seated, they are generally present in the 
late stages, and near the close of the disease. They are much 
more common in grave and fatal cases, than in those of an op- 
posite character. Louis found them present, in some form, 
either that of spasms or permanent rigidity, in one-third of his 
fatal cases ; while of fifty-seven cases, somewhat severe, but ter- 
minating in recovery, there were spasms in only six. Of Dr. 
Jackson's cases, subsultus tendinum was noticed in 1 of 3.36, 
which were fatal, and in 1 of 10.03, which recovered. Perma- 
nent contraction of the muscles, generally of those of the arm, 
is almost invariably confined to cases, which are about to end 
fatally. Dr. Jackson and Chomel report each one instance of 
this kind, which terminated favorably. Subsultus tendinum 
seems to be less frequent in children than in adults. 1 

One of the most constant and characteristic phenomena of 
typhoid fever consists in prostration of the muscular strength. 
In very many cases, this is extreme, even in the early periods of 
the disease. A great majority of patients take to their beds at 
the beginning of the disease, and remain there almost constantly 
until the commencement of convalescence. They will suffer 
themselves to be placed passively in a chair, in order that their 
beds may be made up and aired, but they are impatient and 
anxious to be returned as quickly as possible. When this pros- 
tration is extreme, unless there are great restlessness and distress, 
or delirium, the patient lies continually in the same position, on 
his back, entirely passive, with hardly sufficient strength to move 
his limbs. It is necessary for his attendants to raise him up in 
bed, and to hold to his lips the cup when he drinks. Conversa- 
tion, addressed to him, is irksome and fatiguing, and he answers 
questions with reluctance, and with a painful effort of his ex- 
hausted strength. Forget mentions, in very grave adynamic 
cases, a common position of the patient ; his arms extended upon 
the chest and abdomen, and the hands resting upon the genital 
organs. 

1 Barthez and Rilliet, 



SYMPTOMS. — STATE OF THE MUSCLES. 71 

Of nineteen fatal cases observed by Dr. Jenner, " two were 
able to leave their beds unassisted, and with facility, throughout 
the whole course of the disease. One of the patients died on 
the twenty-fifth day of the disease, and the other five weeks after 
her admission. Two were able to leave their beds with tolerable 
facility respectively up to the fifteenth and twenty-fourth day of 
the disease, but the former on the sixteenth and the latter on the 
twenty-sixth day, were unable, without assistance, to reach the 
close stool placed immediately adjoining the bed. Five patients 
could, though with great difficulty, get out of bed unassisted, 
from the thirteenth to the thirtieth days, while ten were quite 
unable from the fifth to the twenty-sixth days ; there was ex- 
treme prostration in eight cases from the fourteenth to the thirti- 
eth days." 1 

I have already remarked, that this feeling of debility is early 
in its appearance. Chomel says, that patients, in reply to the 
question put to them at the first visit, how they came to the 
Hotel Dieu, always answered " in a carriage, or supported by 
two friends, for we were not strong enough to come alone on 
foot." In nearly all the fatal and grave cases, it is very strongly 
marked ; in mild cases, it is still present, but in a more moderate 
degree. Occasional exceptions are met with. Louis mentions 
instances, in which the patients kept about for a week, and even 
a fortnight, some of them continuing their accustomed occupa- 
tions. Some of these were fatal cases. I have seen one striking 
instance of this character. The patient did not confine herself 
to the bed, until the occurrence of intestinal perforation. 

This debility, when it is once present, rarely disappears or di- 
minishes^ until the close of the disease. A slight increase of 
muscular strength, shown by turning for a short time upon the 
side, or by a disposition to sit a little longer than is necessary 
in tife chair, is one of the first and most cheering indications of 
returning health. 

1 Jenner, &c, p. 26. 



72 TYPHOID FEVER. 

ARTICLE V. 

DIGESTIVE AND ABDOMINAL SYMPTOMS. 

I now come to the consideration of a group of morbid phe- 
nomena, not less extensive, various, and important, than those 
connected with the nervous apparatus. I allude to the symptoms 
consisting in disturbances of the entire complex function of diges- 
tion. These symptoms are more characteristic, indeed, of ty- 
phoid fever, than those which have just been described. We rely 
upon them, as one of our surest means of distinguishing between 
cases of this disease, and those of the analogous form of fever, 
which will next be described, under the name of typhus. For 
this reason, especially, as well as in accordance with the general 
plan and object of this history, I shall treat of them particularly, 
and in detail. 

Sec. I. — Tongue and Mouth. In a certain proportion of 
cases, the tongue is but slightly altered in its appearance, and 
this is true of the disease in all its grades of severity. Even in 
fatal cases, if they terminate early, that is, during the course of 
the second week, it not unfrequently happens that the tongue is 
merely covered with a light fur, and is not quite as moist as it is 
in health. When the disease is very mild, the tongue is often 
almost natural in its appearance, or covered only with a light, 
yellowish coat. At other times, under the same circumstances, 
it is smooth, moderately red, and moist with a tenacious, adhesive 
matter. This glutinous exudation is, indeed, very common, in 
all forms of the disease, the severe as well as the moderate. Be- 
sides this, there are other changes, which are found in a majority 
of cases, especially in those which are grave and protracted. 
Sometimes the tongue, having been covered with a light, or yel- 
lowish, moist coating, for a few days, gradually becomes dry and 
brown in a stripe along its middle, and red at its tip and along 
its edges. In other cases, or later in these, it becomes dark over 
its whole surface; sometimes nearly black, glazed, stiff, and 
crossed by cracks and fissures. Sometimes this dark, dry crust 
peels off in flakes or patches, leaving the mucous membrane 
naked, red, and shining. This process of coating and denuding 
may be repeated several times in the course of a severe and pro- 



SYMPTOMS. — APPETITE AND THIRST. — VOMITING. 73 

tracted case. In a small number of instances there is a whitish, 
aphthous exudation upon the tongue, and also upon other portions 
of the mucous membrane of the mouth, like that which is often 
seen in the last stages of phthisis pulmonalis, and some other 
chronic diseases. It is generally found where the tongue is mor- 
bidly red, and only at a late period of the fever, when there is 
great debility. In these cases, as well as in others, where there 
is a morbid redness, the tongue is not unfrequently swollen, pain- 
ful, and tender. Now and then, it is the seat of ulceration. The 
cracked, brown, and blackish tongue is not so common amongst 
children as it is in adults. 1 

The patient often finds a good deal of difficulty in protruding 
the tongue, particularly when it is dry, stiff, and fissured, or 
covered with the tenacious secretion. Under these circumstances, 
even if the mind is sufficiently clear, and the will active, the tip 
and sides stick to the lips, and it is only after repeated efforts 
that it is finally put out. Not unfrequently, it is protruded with 
a tremulous motion. 

The dryness and redness of the mucous membrane often ex- 
tend to the different portions covering the posterior fauces, giving 
rise to more or less difficulty of swallowing, and to other disa- 
greeable or painful sensations. The lips are also often cracked 
and covered with dry crusts, and the teeth, especially near the 
gums, are lined with a dark, tenacious sordes. The secretion of 
saliva is commonly scanty, and its quality changed. 

Sec. II. — Appetite and Thirst. The desire for food is almost 
invariably absent, from the beginning to the end of the disease. 
The very idea of eating is offensive. A return of the appetite is 
amongst the earliest indications of recovery. The thirst is, in 
most cases, proportionate to the degree of febrile excitement. 
Sometimes, especially during the paroxysm of fever, it is urgent. 
Cool drinks are commonly preferred, but not always. 

Sec. III. — Nausea and Vomiting. A majority of patients 
with typhoid fever suffer more or less with gastric symptoms. 
The most frequent of these are nausea, vomiting, and epigastric 
distress. Of twenty-four fatal cases mentioned by Louis, there was 
nausea in thirteen, occurring at various periods of the fever, and 

1 Barthez and Killiet. 



74 TYPHOID FEVER. 

continuing for an uncertain length of time. Of twenty-three fatal 
cases, vomiting was present in twelve. Nausea not unfrequently 
occurs at or near the commencement of the disease ; but vomiting 
takes place more frequently at a later period, especially when the 
matter ejected is of a greenish color and bitter taste, and when 
there is also present epigastric pain or distress. This combina- 
tion of symptoms was first particularly noticed by Louis, and, as 
I shall have occasion to say hereafter, was shown by him to be 
associated with a peculiar lesion of the stomach. Vomiting, at 
or near the commencement of the disease, is more frequent in 
cases of children, than in those of adults. 

Pain or distress in the region of the stomach, varying consider- 
ably in character and severity, is still more common than either 
nausea or vomiting. Finally, there are many instances, in which 
patients go through the fever without the occurrence of any one 
of these strictly gastric symptoms. In regard to this point, Na- 
than Smith says : "Sometimes, nausea and vomiting take place. 
Sometimes, the matter thrown up consists wholly of vitiated mu- 
cus ; at others, it is mixed with bile of an unhealthy color and 
consistence." 1 

Sec. IV. — State of the Bowels. Amongst the most frequent, 
and when taken in connection with other phenomena amongst 
the most characteristic, symptoms of typhoid fever, is diarrhoea. 
This symptom varies very much in different cases, in regard to 
the period of its commencement, its degree, its duration, and so 
on. As a general rule, it is most common and severe in long- 
continued and grave cases, and least so in those of an opposite 
character. It was present in all but three of Louis's fatal cases. 
When the disease is mild, it is frequently wholly absent. It varies 
in severity, from one or two discharges to twenty, or more, in 
the course of twenty-four hours. It commences at different 
periods of the fever. Of forty fatal cases, cited by Louis, in 
which this point was precisely ascertained, diarrhoea was present 
on the first day of the disease in twenty-two. In others, it begun 
from the third to the fourteenth day. 2 In mild cases, it is fre- 
quently wanting, and, when present, commonly makes its appear- 
ance later in the disease, is less urgent, and of shorter continu- 

1 Smith's Medical and Surgical Memoirs, p. 64. 

2 Louis's Researches, vol. i. p. 464, 2d ed. 



SYMPTOMS. — STATE OF THE BOWELS. 75 

ance. It is commonly a protracted symptom in severe cases, its 
average duration, according to Louis, being nearly four weeks. 
Nathan Smith says: "The latter stage of all severe cases is 
attended with diarrhoea." In fatal and grave cases, late in the 
disease, the discharges are often involuntary, and wholly without 
the consciousness of the patient. 

The stools are generally liquid, somewhat turbid, and of a 
yellowish color, in appearance not unlike new cider. In a con- 
siderable number of cases, they are of a dark brown color. Their 
smell is fetid and offensive. Occasionally, they contain portions 
of blood, and sometimes free and repeated hemorrhage takes 
place from the bowels. According to Dr. Jackson, this discharge 
occurred, in the Massachusetts General Hospital, in about one- 
tenth of the cases. In seven out of twenty-one fatal cases 
observed by Dr. Jenner, there was hemorrhage from the bowels. 
" In one, discharges of blood took place on the sixth and seventh 
days of the disease. On the tenth, the stools were healthy in 
appearance, and well formed ; and, although they afterwards be- 
came watery, there was no return of the hemorrhage. One man 
passed a small quantity of blood on the eighth, ninth, and tenth 
days of the disease, and again from the twenty-eighth to the 
thirty-second — i. e. the day of death — the stools between the 
two attacks of hemorrhage being watery, but free from blood. 
In one case, blood was mixed or passed with every stool, from the 
fourteenth to the twenty-first day, the patient dying on the 
twenty-fifth day. In four cases, hemorrhage from the bowels 
occurred during the last day or two of life, the patients dying 
respectively on the seventeenth, twenty-third, twenty-fifth, and 
twenty-eighth days of the disease. The blood lost varied in 
quantity from an ounce or two, to two or three pints ; in hue, 
from black to bright red; and in consistence, from a reddish 
watery fluid to the consistence of treacle, and even solid clots." 1 

It appears, from the researches of M. Taupin, to be less fre- 
quent in patients under fifteen years, than amongst adults. He 
met with but one instance, in one hundred and twenty-one cases ; 
and Barthez and Rilliet, in one hundred and eleven cases, met 
with none. A more exact estimate of the importance of this 
symptom, as well as of others, as a means of prognosis, will be 

i Jenner, &c, p. 32. 



76 TYPHOID FEVER. 

made hereafter. Louis says it is exceedingly rare to find any 
mucus in the dejections. 

Dr. Hale, of Boston, thinks that diarrhoea is a more frequent 
symptom in the typhoid fever of Paris, than in that of New 
England; and the Report of Dr. Jackson seems to corroborate 
this opinion. This may be so, but I do not think that the data 
from which the opinion is derived are sufficiently accurate and 
positive to settle this matter. It seems very probable that the 
records of the Massachusetts General Hospital do not always 
call that condition of the alvine evacuations, diarrhoea, to which 
the term is applied by Louis. It is true, at any rate, that such is 
the case with the great mass of American practitioners. Cer- 
tainly, as a general rule, they do not, as Louis does, apply the 
term diarrhoea to that state of the bowels, in which only one or two 
thin discharges occur in the course of twenty-four hours. In 
this way, the apparent difference may, perhaps, be accounted for. 

Professor Schonlein of Zurich, in 1835, found in the intestinal 
discharges a great number of microscopical crystals, perfectly 
transparent, slightly fragile, soluble in muriatic and nitric acids, 
and consisting chiefly of phosphate of lime, some sulphate of 
lime, and a salt of soda. Similar crystals were subsequently 
found, but in much smaller quantity, and much less constantly, 
in the intestinal discharges in other diseases. 1 

Diarrhoea, according to Barthez and Rilliet, is invariably pre- 
sent in the typhoid fever of children. 

Sec. V. — Abdominal Pains. Pain in the abdomen is another 
very common accompaniment of typhoid fever. Its severity and 
frequency are in pretty direct relation to the severity of the dis- 
ease, and to the extent of the diarrhoea. Like the latter symptom, 
the pains in the abdomen are often present at the beginning of 
the fever. At other times, the pain appears at different periods 
of the disease. In some cases, it is only elicited by pressure, but 
more frequently, it is independent of this. It varies in severity, 
from a dull heavy ache, or feeling of distress, to a severe, colicky 
griping. It is not often diffused over the whole abdomen, its 
most common seat being the iliac fossae, the hypogastrium, and 
around the umbilicus. This symptom, in many cases, constitutes 

> Edin. Med. and Surg. Journ., vol. xlviii. p. 253. 



SYMPTOMS. — TYMPANITES. 77 

the principal source of suffering to the patient, during nearly 
the entire progress of the fever. 

In a certain proportion of cases, generally after the middle 
period of the disease, and sometimes during convalescence, there 
is a sudden supervention of very acute pain in the abdomen, at 
first confined to a small space, but extending pretty rapidly over 
the entire belly. The pain is accompanied by great tenderness 
on motion, or pressure ; tympanitic distension ; rapid, feeble, and 
thready pulse ; extreme distress ; nausea and vomiting ; pinched 
and cadaveric features ; and these phenomena are speedily fol- 
lowed by death. These are the signs of an acute peritonitis ; 
the consequence of intestinal perforation. 

Sec. VI. — Tympanites. Flatulent distension of the abdominal 
parietes is a very common, and to a considerable extent, charac- 
teristic symptom of this disease. Its degree and frequency, like 
the diarrhoea and abdominal pains, with which it is often associ- 
ated, are, for the most part, proportionate to the gravity of the 
disease. It is commonly later in its appearance than the other 
gastro-intestinal symptoms, showing itself, often, during the 
second and third weeks of the fever. Dr. Hale, in his very ex- 
cellent paper, remarks that this symptom is found most frequently 
near the beginning of the disease. 1 This is directly opposed to 
the result of my own observation, and I think to the best autho- 
rities. It varies in degree, from a slight rigidity of the muscles 
and straightness of the parietes, to the extremest distension ; in 
these cases occasioning, as has already been remarked, by its 
mechanical action on the lungs, no inconsiderable degree of dys- 
pnoea. It generally persists, after its first appearance, till the 
fatal termination, or the approach of convalescence ; although it 
is not unusual for it to vary considerably in degree, at different 
periods of the fever. The flatus rarely passes off per anum, and 
seems to be but little disturbed by the peristaltic motion of the 
intestines. 

There is another symptom connected with the abdomen, which 
may be mentioned here. It was first particularly noticed, so far 
as I know, by Chomel, though it can hardly have escaped the 
attention, I think, of all who have had much to do with the dis- 

1 Med. Com. Mass. Med. Soc, 1839. 



78 TYPHOID FEVER. 

ease. I allude to the gurgling sound, which is produced by 
pressure on the abdomen, especially over the region of the coecum. 
If the distension is not excessive, pretty firm pressure, made alter- 
nately with each hand, in the manner of seeking for deeply- 
seated fluid, will rarely fail, I think, to elicit this sensation and 
sound. It is chiefly interesting as one of the elements of our 
diagnosis. 

ARTICLE VI. 

MISCELLANEOUS SYMPTOMS. 

Under this head, I have still to enumerate and describe a cer- 
tain number of morbid phenomena, more or less important, and 
more or less characteristic of typhoid fever, which could not well 
be grouped in any other manner. 

Sec. I. — Emaciation. In most cases of the fever, there is a 
well-marked and gradually progressive emaciation, although it is 
not often very obvious before the end of the second week. Where 
the disease is severe and prolonged, this emaciation is often ex- 
treme. In cases of great severity, terminating fatally at an 
early period, this symptom is hardly noticed. 

Sec. II. — State of the Urine. Modifications in the urinary 
secretion are generally present. Nathan Smith says : " In the 
commencement of the fever, the urine is not high-colored, and is 
considerably copious, being often above the natural quantity, and 
deposits no sediment. In voiding it into a vessel, it often foams 
like new beer. As the disease advances, the urine becomes more 
highly colored, and as it begins to decline, lets fall an abundant 
sediment. In very severe cases, the patient evacuates his bladder 
but seldom, allowing the urine to accumulate there in very large 
quantities." 1 Drs. Dobler and Skoda, in a description of the 
typhoid fever of Vienna, inform us, that, whenever the disease is 
at all severe, the urine deposits no sediment, unless it be a slight 
cloud of mucus. On the subsidence of the fever, there is often a 
grayish, dirty deposition. 

1 Smith's Medical and Surgical Memoirs, p. 64. 



SYMPTOMS. — EPISTAXIS. — CUTANEOUS ERUPTIONS. 79 

Sec. III. — Epistaxis. Hemorrhage from the mucous mem- 
brane of the nostrils is quite common in the course of typhoid 
fever. Louis ascertained its occurrence in twenty-seven of thirty- 
four patients, who had the fever in a grave form, but recovered. 
It was present in somewhat less than half of his mild cases. It 
may occur at different stages of the disease, but it is most common 
during the early period, or in the first half of its duration. It 
sometimes occurs but once, but is, in many instances, several 
times repeated. It is generally small in quantity, sometimes 
amounting to only a few drops. At other times it is profuse, re- 
quiring the use of the tampon to arrest it. It is rarely, if ever, 
attended with or followed by any relief. It seems to be much 
less common amongst children, than amongst adults. 1 

Sec. IV. — Cutaneous Eruptions. The most frequent and cha- 
racteristic eruption upon the skin consists in what has been called 
the lenticular, rose-colored spot. This, indeed, is so common in 
typhoid fever, and so rarely seen in any other disease, that it has 
received the name of typhoid eruption. It consists of a small 
spot, not a pimple, slightly elevated above the surrounding skin, 
not always sensible to the touch, but generally so, about as large, 
in circumference, on an average, as the head of a pin, and of a 
bright red, or rose color. When the skin is made tense, or pressed 
by the finger, the spot readily disappears, returning immediately 
on the removal of the pressure. 

There is good reason to think that this eruption is almost an 
invariable accompaniment of typhoid fever. It is true, that 
amongst thirty-six fatal cases, where the eruption was sought for, 
Louis found it in only twenty-six. So, in the Massachusetts 
General Hospital, Dr. Jackson found, during the years 1833, 
1834, and 1835, the rose spots in only two-thirds of the patients. 
But it is very probable that, in many of these cases, the eruption 
was either overlooked, or that it had disappeared before the 
patients came under the care of their respective physicians. All 
the grave cases, which recovered, cited by Louis, excepting 
three ; and all his mild cases, without any exception, exhibited 
this eruption. Dr. Hale found the rose spots in one hundred 
and seventy-seven of one hundred and ninety-seven cases, and in 

i Louis's Researches, vol. ii. p. 84, 2d ed. 



80 TYPHOID FEVER. 

a greater part of the remaining twenty, they were not carefully 
sought for. 1 

Louis says, in his second edition, that of fifty-four cases, care- 
fully and daily observed, at La Pitie' and the H6tel Dieu, subse- 
quent to the publication of his Researches, the rose eruption was 
present in all but five. In these it was wholly wanting. I have 
rarely failed to find it, where it was properly sought for. Dr. 
Jenner says: "My impression is that the rose spots of typhoid 
fever are more frequently absent from patients more than thirty 
years old, than from those of less mature age. I should say they 
were rarely absent in young persons. This is, however, the 
reader must remember, merely a general impression." 

It appears, from the observations of Rilliet and Taupin, that 
this sign is as common in early as it is in adult life. It frequently 
appears a day or two sooner in cases of children. Taupin says 
that he has never seen this eruption in the course of any other 
disease amongst children, and he mentions particularly menin- 
gitis; of which he has witnessed more than two hundred cases. 2 

It is found on various parts of the body, but much more fre- 
quently than elsewhere upon the abdomen and the chest. Now 
and then, it is seen upon the skin of the extremities and of the 
face. It is also found upon the back. 

The spots vary in number. Sometimes, they are but few — 
six, eight, or ten. In other cases, they are much more numerous, 
being sprinkled pretty abundantly over the chest and abdomen. 

Dr. Jackson, of Boston, informs me, that he has seen them 
quite thickly scattered over the entire surface, even that of the 
limbs. I have this day, August 6, 1842, visited a patient, sick 
about a fortnight with typhoid fever, who exhibits the spots upon 
every part of the skin, excepting that of the hands, ankles, and 
feet. There are not less than twenty upon the face, and as many 
as forty may be counted on the left arm between the elbow and 
wrist. Their size varies from that of a small point to a diameter 
of two lines. Most of them are pretty regular in their oval or 
circular outline, although a few of the larger ones are less so. 
They are, many of them at least, slightly but very distinctly 
elevated above the surrounding skin, and can be readily detected 
by the finger. 

1 Com. Mass. Med. Soc, 1839. 

2 Louis's Researches, vol. i. p. 106, 2d ed. 



SYMPTOMS. — CUTANEOUS ERUPTIONS. — ESCHARS. 81 

The most usual period of their appearance is during the second 
week of the fever. In a few rare instances, they are seen as 
early as the close of the first week. Of twenty-five cases, in 
which this point was carefully noticed by Chomel, the eruption 
appeared between the sixth and the eighth day of the disease, in 
two ; between the eighth and the fifteenth day, in thirteen ; be- 
tween the fifteenth and the twentieth day, in seven ; between the 
twentieth and the thirtieth day, in four ; and on the thirty-seventh 
day in one. 1 They generally come out successively, one after 
another, and after remaining, commonly, for little more than a 
week, they successively and gradually fade away and disappear. 

The following is Dr. Jenner's description of the rose spots. 
" They were slightly elevated. To detect the elevation, the finger 
had to be passed very delicately over the surface, as they had 
none of the hardness of the papulae of lichen, or of the first 
day's eruption of smallpox. Their apices were never acumi- 
nated, never flat, but invariably rounded ; their bases gradually 
passed into the level of the surrounding cuticle. No trace of a 
vesicle or white spot of any kind was ever detected on them. 
They were circular and of a bright rose color, the latter fading 
insensibly into the natural hue of the skin around. They never 
possessed a well-defined margin. They disappeared completely 
on pressure, resuming their characteristic appearances as soon as 
the pressure was removed ; and this was true from first to last. 
from their first eruption to their last trace. They left no stain 
of the cuticle behind ; they never passed into anything resembling 
petechiae ; the characters they presented on their first appear- 
ance continued till they vanished. Their ordinary size was about 
a line in diameter, but occasionally they were not more than half 
a line, and sometimes a line and a half in diameter. The dura- 
tion of each papula was three or four days ; fresh papulae made 
their appearance every day or two. Sometimes only one or two 
were present at first, ran the course above described, and then 
one or more fresh ones made their appearance, vanished in three 
or four days, and were followed by others to last as long. The 
number of papulae seen at one time on the surface was ordinarily 
from six to twenty; though occasionally there was only one, and 
sometimes more than a hundred. 

1 Chomel. p. 20. 

6 



82 TYPHOID FEVER. 

" They usually occupied the abdomen, thorax, and back, but 
were occasionally present on the extremities. One was frequently 
noticed on the thorax, over the cellular interval, at the upper 
border of the pectoralis on either side. A very pale and delicate 
scarlet tint of the skin sometimes preceded the eruption of the 
papulse, but never lasted more than a day or two ; the skin 
resembling in tint that of a person shortly after leaving a hot 
bath. Rose spots were present in nineteen of the twenty-three 
fatal cases here analyzed." 1 

Another pretty common eruption consists in transparent vesi- 
cles, to which the name sudamina has been given. These vesi- 
cles are circular, or oval in their shape, varying in size from that 
of a small pin's head, to that of a split pea. They are formed 
by the presence of a limpid fluid elevating the cuticle. Their 
most frequent seat is upon the sides of the neck, and about the 
shoulders and axillae, though they are sometimes scattered more 
extensively over the body. Chomel says that he has never seen 
them on the face. They are most readily seen, when looked at 
in an oblique direction. They appear late in the disease, being 
rarely seen before the twelfth day. They usually remain for 
several days, and gradually disappear. They were present in 
two-thirds of Louis's cases, where they were carefully sought for, 
and in the same proportion, whatever was the severity of the 
fever. Dr. Hale attaches much less importance to sudamina as 
a diagnostic sign of typhoid fever than Louis and Chomel. He 
say's : " Wherever the skin is for a length of time kept in a state 
of perspiration, from whatever cause, there sudamina will gene- 
rally be found." This is far from being in accordance with the 
observations of Louis and Chomel. Louis says, that of forty 
patients with other diseases, in all of whom there were copious 
sweats, only three exhibited sudamina. 

Sec. V. — Eschars. In this place may be properly noticed the 
tendency which exists, particularly in grave and protracted cases 
of typhoid fever, to ulceration of the skin. This is occasionally 
shown in the formation of ulcers upon the sacrum. In similar 
cases, it not unfrequently happens that blistered surfaces are 
attacked with ulceration. They become, especially about the 

1 Jenner, &c. ? p. 12. 



SYMPTOMS. — ESCHARS. 83 

edges, covered with a white or grayish exudation, like that which 
is frequently seen on blistered surfaces, in cases of protracted 
scarlatina, and which is commonly called canker. The ulceration 
underneath this matter sometimes becomes deep and extensive, 
adding, in no small degree, to the irritation of the disease. In 
some cases, true gangrene occurs, followed by eschars and slough- 
ing. 

In a moderate proportion of grave cases, typhoid fever is com- 
plicated with erysipelatous inflammation of the skin. I have 
known this erysipelatous tendency show itself in a disposition to 
attack the end of the nose. Biles appear, occasionally, upon 
different parts of the body, on the approach, or after the com- 
mencement of convalescence. 

I have now completed the enumeration and description of the 
symptoms of typhoid fever. Some of these symptoms are more 
important, more frequently present, and more characteristic of 
the disease, than others. Some, again, are chiefly interesting 
and valuable as diagnostic, and others as prognostic, indications. 
It very rarely happens that, in any single case, they are all 
united. Under different circumstances, and in different cases, 
they are very variously combined, constituting different grades 
and varieties of the disease. These varieties might, properly 
enough, be described in this place ; but I think it better to defer 
this description, until after the anatomical lesions of the disease, 
and the relations, so far as these have been ascertained, between 
the symptoms and the lesions, have been given. I shall thus be 
enabled to present to the reader a more distinct, individualized 
and unbroken picture of the disease, with its ordinary and 
average features, than can otherwise be done. The varieties in 
its march, in its severity, in the grouping and combination of its 
numerous symptoms, will then be considered, in their place, 
amongst the other complex elements in the natural history of the 
disease. 



84 



CHAPTER III. 

ANATOMICAL LESIONS. 

Chomel, in his very excellent and full description of the patho- 
logical alterations in typhoid fever, divides them into two classes, 
consisting, respectively, of those which are constant and charac- 
teristic, and of those which are occasional. Louis does not 
attempt to follow any natural or systematic arrangement. In 
the present history, as a matter of convenience, I shall pursue, 
as far as this can well be done, the same general order in the 
succession of subjects, that I adopted in the detail of symptoms; 
pointing out, under each head, the connections between the 
symptoms of the disease, and the lesions of the organs, so far as 
this connection has been ascertained. 

ARTICLE I. 

LESIONS OF THE CIRCULATORY APPARATUS. 

Sec. I. — Heart and Aorta. The most striking and common 
alteration of the heart consists in a diminution of its consistence. 
Louis found this organ natural, in volume, color, and consistence, 
in one-half of his cases. In seventeen of forty-six cases, the 
softening was very well marked. Its tissue could be very readily 
torn and broken down. At the same time, the heart is exceed- 
ingly flaccid, assuming, when removed from the body, a collapsed 
and flattened shape. The softening of the texture, and the gene- 
ral flaccidity, are most commonly found together, though they 
may exist separately. Under these circumstances, the cut sur- 
faces of the heart have a dull, dry appearance, and the walls of 
the ventricles are, in most cases, diminished in thickness. 1 These 
changes in the condition of the heart are usually accompanied 

1 Louis's Researches on Typhoid Fever, toI. i. p- 331, 



LESIONS. — HEART AND AORTA. 85 

with alterations in its color. The muscular tissue and the exter- 
nal surface are pale, in many cases, with a violet or livid tinge. 
The internal surface is sometimes pale, and sometimes of a more 
or less deep, violet red. The alterations are found more fre- 
quently and more strongly marked, in cases -which have termi- 
nated early, than in those which have been prolonged. Of 
fifteen cases examined by Dr. Jenner, the heart was firm or 
healthy in consistence in five ; soft and flabby, or flabby only in 
five ; the right ventricle flabby, the left normal, in one. Of four 
cases no note on this point was made, but the heart was proba- 
bly healthy. The average duration of the disease in the five 
cases in which the heart was flabby, was twenty-two days ; in the 
five cases in which it was healthy, the average duration was 
twenty-eight days. 1 

It would seem that, at the Massachusetts General Hospital, 
lesions of the heart are of less frequent occurrence. Of twenty- 
eight cases noticed in Dr. Hale's remarks, only two or three are 
said to have been "rather flaccid." It ought, however, to be re- 
membered, that this term might be applied to the same condition 
of the heart by one observer, and withheld by another. There 
have been differences of opinion, amongst pathologists, in regard 
to the nature of these lesions. I do not think there is any e 
factory evidence that they are inflammatory. 

The aorta is frequently more or less changed in color, on its 
internal surface. This change existed in somewhat more than 
one-half of Louis's cases. It consists of a morbid redness, more 
or less intense, sometimes in the form of bands or patches, some- 
times generally diffused over the whole surface, and extending to 
the bifurcation of the aorta, or even considerably beyond it. This 
redness reaches through the inner, and affects, though in a less 
degree, the middle membrane of the cardiac cavities. The in- 
tensity of the morbid color is generally in proportion to the soft- 
ening and flaccidity of the tissue of the heart. It is always 
found in connection with the presence of blood in the aorta ; and 
it is important to remark, further, that the most extreme cases of 
softening of the heart commonly coexist with the presence of a 
dark, soft, non-fibrinous clot of blood in its cavities, or with blood 
not coagulated, but containing bubbles of air. 2 

1 Jenner, &c, p. 80. 

2 Louis's Researches on Typhoid Fever, vol. i. p. 333. 



86 TYPHOID FEVER. 

The cause and nature of this reddening of the inner coats of 
the aorta have been the subjects of much investigation and much 
controversy. There is no place for any account of them here. I 
will merely say that the opinion of Louis seems to me most in 
accordance with all the phenomena which enter into the solution 
of the question ; and that opinion is, that this redness is the result 
of imbibition, by the tissues, of the coloring matter of the blood — 
the imbibition depending upon a special condition of the blood, 
or of the tissues, or, perhaps, of both. There is no conclusive 
evidence, at any rate, that the redness is the result of inflamma- 
tion. 

Sec. II. — State of the Blood. The most frequent alteration 
in the character of the blood consists in the diminution of the 
natural proportion of its fibrine. In some cases, the cavities of 
the heart, especially the right, contain fibrinous concretions of a 
whitish or yellowish color ; but more commonly, the blood is in 
the form of dark coagula, or entirely fluid. Of thirty cases, 
wherein the blood, contained in the heart and aorta, was carefully 
examined by Chomel, he found small and scanty fibrinous concre- 
tions in six, dark coagula in nine, and dark, fluid blood in fifteen. 
The occasional presence of air in this uncoagulated blood has al- 
ready been noticed. According to the observations of Louis, the 
appearance of the blood, contained in the cavities of the heart, as 
has just been intimated, varies with the condition of this organ. 
When its consistence was natural, he found, especially in the 
right cavities, yellowish or whitish fibrinous coagula, more or 
less firm; when it was considerably softened, he found non- 
fibrinous coagula; and when the softening was very great, instead 
of coagula, he found only a small quantity of fluid blood contain- 
ing air. 

Blood drawn from the veins, during life, rarely exhibits the 
buffy coat ; and when this is present, it is generally soft, gela- 
tinous, or infiltrated, and of a grayish or greenish color. This 
character of the blood has been particularly noticed by Louis, 
Chomel, and Bouillaud ; and the results of their observations have 
been abundantly verified by the subsequent and more accurate 
researches of Andral and Gavarret. They found that, in typhoid 
fever, the proportion of fibrine in the blood was never increased 
above its natural standard; but on the contrary that, in many 



LESIONS. — RESPIRATORY APPARATUS. 87 

cases, this proportion was very much diminished ; and, farther- 
more, that the degree of this diminution was very uniformly pro- 
portionate to the severity of the disease. These observers found 
a similar alteration of the blood in the eruptive fevers, while in 
all cases of simple acute inflammation, the quantity of fibrine was 
above its natural standard. 



ARTICLE II. 

LESIONS OF THE RESPIRATORY APPARATUS. 

Sec. I. — Lungs. Neither the symptoms nor the lesions go to 
show that the lungs play any very important part in the nume- 
rous and complicated phenomena of typhoid fever. Louis found 
them nearly natural in fifteen of forty-six cases ; about the same 
proportion in which he found them so in other acute diseases, 
excluding, of course, those of the lungs themselves. Chomcl 
found them healthy in ten of forty-two cases. The most charac- 
teristic alteration is described particularly by Louis, and, so far as 
I am aware, had not been noticed by other writers. It is of fre- 
quent occurrence in the fever of our own country. It has been 
called splenization, or carnification of the lung. The latter term 
may be well enough, but the former is wholly inappropriate ; the 
appearance of the lung being entirely unlike that of the spleen. 
The portion of lung thus carnified, is of a deep, bluish-red color; 
it has a tough, leathery feel; the finger penetrates and breaks it 
down with difficulty; it is wholly destitute of air, and sinks 
readily in water. When it is cut, the smooth surface is directly 
covered with a thick, red fluid. This peculiar lesion almost 
always occupies a circumscribed portion of the lower and posterior 
lobe of one or both lungs. It is quite unlike, in almost every 
respect, the second stage of inflammation, although the term 
hepatization has sometimes been applied to it. It is not indi- 
cated by any peculiar symptom during life. Dr. Jenner gives 
the following description of this lesion, which he calls Lobular 
non-granular Consolidation. "Externally, a portion of lung in 
this condition has a mottled aspect; here and there are patches, 
varying in size from a single lobule to half or more of a lobe, of 
a deep bluish, chocolate, violet, or purplish slate color, bounded 
by a well-defined angular margin, crossed, if it includes more than 



88 TYPHOID FEVER. 

one or two lobules; and mapped out into smaller patches, by- 
dull opaque whitish lines. On closer inspection, the outline and 
the whitish lines intersecting the patches, are seen to be thick- 
ened interlobular septa. 

" Scattered in the midst of the larger patches, are frequently 
found one or more comparatively healthy lobules, of a pale 
brightish pink color, contrasting strongly with the hue of the 
surrounding tissue. Here and there, near the border of the 
large patches, may be seen, occasionally, lobules, the centres of 
which have assumed the dusky purplish tint; the circumference 
of the same lobules yet retaining their healthy color. The dark 
patches feel solid and flabby; the pulmonary tissue, at these 
spots, has lost the resiliency of health. The pleura covering the 
lungs either retains its natural appearance, or has a ^ slightly 
milky aspect. On section, the tissue corresponding to the dark 
patches, is found to be of a deep purplish chocolate color, gorged 
with non-aerated bloody-looking fluid, breaks down with little or 
no increased facility, nay, sometimes appears tougher than in 
health ; has a uniform or nearly uniform section, i. e. there is no 
appearance of granules, such as are seen in the consolidation and 
non-consolidated state of so-called vesicular pneumonia ; sinks in 
water, like the patches seen externally; is bounded by interlobular 
septa; but these divisions, between the consolidated and non- 
consolidated tissues are less marked, especially the most super- 
ficial tier so to speak, of lobules. A minute portion can be cut 
from the middle of a lobule — the centre of which is dark purple, 
and the circumference brightish pink — which sinks in water; 
equally small pieces of pulmonary tissue, from the circumference 
of the same lobule, float." 1 

Other changes, such as inflammation, usually not extensive ; 
simple mechanical engorgement, taking place during the last 
hours of life; violet red spots or patches in the infer o-posterior 
portions of the lung; circumscribed abscesses and tubercles are 
present in a certain proportion of cases. The inflammation is 
often not discoverable during life, except by its physical signs. 

Sec. II. — Bronchia, Epiglottis, $c. The mucous membrane 
of the bronchial tubes is frequently of a more or less livid red 

1 Jenner, &c, p. 86. 



LESIONS. — BRAIN AND ITS MBMBRAJTES. 89 

color, sometimes with a violet tinge. That of the trachea is occa- 
sionally colored in the same manner, but is very rarely the seat 
of any unequivocal lesion. The same thing is true of the larynx. 
The epiglottis is more frequently and seriously diseased. In a 
moderate proportion of cases, it is the seat of ulcerations, extend- 
ing not only through its investing membrane, but into the fibro- 
cartilage itself; occasioning, sometimes, extensive destruction of 
the organ. In other cases, it is simply denuded. These ulcera- 
tions arc not found where the disease is rapidly fatal. They are 
frequently productive of some difficulty of swallowing. 

Recent lesions of the pleura are very rare. In many cases, 
there is an effusion of bloody serum, varying in quantity, from a 
few ounces to a pint or more, occupying both sides of the chest. 
This exudation probably takes place near the close of life. 



ARTICLE III. 

LESIONS OF THE BRAIN AND ITS MEMBRANES. 

From the frequency and severity of the symptoms, consisting 
in deranged action of the brain, it would have been supposed. M 
a mere matter of a priori reasoning, that this organ would haw 
exhibited corresponding alterations in its appearance. Such, 
however, is far from being the fact. As will be seen by the 
details which I am about to give, lesions of the brain are far 
from being universally present, and, when present, far from being 
found in any constant relation to the disturbed functions of the 
organ during life. Of thirty-eight cases, reported by Chomel, in 
which the brain and its membranes were carefully examined, fif- 
teen presented no appreciable alterations in these organs. 1 The 
most common changes, in a certain proportion of cases, consist of 
moderate serous effusion between the arachnoid and pia mater ; 
more or less vascularity of the pia mater itself; a rosy tinge of 
the cortical substance, and injection of the medullary portion of 
the brain. Of forty-six cases, Louis found the sub-arachnoid 
effusion, various in degree, in twenty-eight ; vascularity of the 
pia mater in somewhat less than one-half; the rosy tinge of the 
cortical substance, uniformly diffused through its entire extent, 

1 Ckomel's Le§ons de Clinique Medicale, p. 294. 



90 TYPHOID FEVER. 

in seventeen, and more or less injection of the medullary sub- 
stance in all but eight. This injection is generally proportionate 
to the red color of the gray substance, and both phenomena are 
most common and strongly marked in cases which terminate 
early. The serous effusions, on the other hand, are more fre- 
quently found in cases that have been protracted. In rare in- 
stances, there is a slight increase or diminution in the consistence 
of the brain, besides some other unimportant and accidental 
alterations. 

In regard to the nature of these several lesions, there is, 
amongst pathologists, a difference of opinion. Those who still 
cling to the doctrines of the old and exclusive physiological school, 
and who are haunted by the perpetual presence of irritation, 
regard the foregoing changes as the evidence and result of in- 
flammatory action. Others think, that not only is there no 
satisfactory proof of the action of this morbid element, but that 
there are many and insuperable objections to such an opinion. 

There is no ascertained relation between the cerebral symptoms 
during life, and the pathological conditions of the brain and its 
membranes, appreciable after death. Delirium and somnolence 
are found to have occurred as frequently, and to have been as 
strongly marked, in patients whose brains presented no changes, 
or exceedingly slight ones, after death, as in those of an opposite 
character. Again, it is obvious, that these lesions are in no 
way peculiar to typhoid fever, since they are found almost as 
frequently in patients dead from other acute diseases, excluding 
those of the brain itself and its envelops, as in those dead from 
the fever. 

ARTICLE IV. 

LESIONS OF THE DIGESTIVE AND ABDOMINAL ORGANS. 

Sec. I. — Pharynx and (Esophagus. In a large proportion of 
cases of typhoid fever, these organs are found in their natural 
state. The only lesion of any considerable frequency, which 
they exhibit, consists in ulcerations of their mucous lining. 
These were noticed by Louis, in the pharynx, in eight of forty- 
six cases ; and in the oesophagus, in nearly the same proportion. 
They vary in size, from one to six or eight lines in diameter, are 
circular or oval in shape, and generally quite superficial. In 



LESIONS. — STOMACH. 91 

many of these cases, there is difficult or painful deglutition. In 
others, especially where there is delirium, this symptom is wholly 
wanting, as it sometimes is, under the same circumstances, in 
cases of ulceration and partial destruction of the epiglottis. 

Dr. Jenner found inflammation, with or without ulceration of 
the larynx and pharynx, in about half of his cases. His analysis 
leads him to conclude that the laryngeal is secondary to the 
pharyngeal affection; and that u in typhoid fever laryngitis, in- 
dependent of pharyngitis, is extremely infrequent.' 11 

Sec. II. — Stomach. The mucous membrane of the stomach, 
unlike that of the pharynx and oesophagus, is generally more or 
less removed from a healthy condition. Louis found it free 
from any obvious lesion, excepting an occasional slight change of 
color, in about one-third only of his cases. The alterations of 
which it is the seat are various. The most common consist of 
changes in its color, its consistence, its thickness, in mamellona- 
tion, and ulceration. These alterations may exist separately, or, 
as happens more frequently, two or more of them are found 
together. The most common change of color consists of increased 
degrees of redness. This redness is of various shades, occupies 
different portions of the stomach, most commonly the great tube- 
rosity, and seems to be dependent on different causes. Sometimes, 
even when not connected with any other change in the membrane, 
it is, probably, the result of inflammatory action ; but, in many 
instances, there is sufficient evidence that such is not the case. 

Softening of the mucous membrane, sometimes existing as a 
simple lesion, is frequently associated with a diminution of its 
natural thickness. This alteration, either simple or complicated, 
is found in all parts of the membrane, but it is oftenest confined 
to that of the cardiac extremity. Of fourteen cases mentioned 
by Chomel, the softening was limited to this region in ten. In 
some cases, it exists in separate bands ; in others, it spreads over 
a continuous portion of the stomach. The thinning occasionally 
extends through the membrane, resulting, of course, in its entire 
destruction. The softening with thinning is found, nearly always, 
in those cases which terminate before the twenty-fifth day of the 
fever. 2 

1 Jenner, &c, p. 49. 

2 Louis's Researches on Typhoid Fever, vol. i. p. 173, 1st ed. 



92 TYPHOll) FEVER. 

Ulcerations of the mucous membrane are present in a few in- 
stances. Louis found them in four of forty-six cases. Of forty- 
two cases quoted by Chomel, they were not found in any. These 
ulcerations are small in size, superficial, and not very numerous. 
There is another pathological state of the gastric mucous surface, 
to which the name mamellonation has been applied. This lesion 
consists of small elevations of the membrane, pretty regularly 
circular, or oval in their form, and scattered thickly, and in con- 
siderable numbers over different portions of the stomach. This 
peculiar condition generally exists, in connection with other alter- 
ations, especially with softening, and increased redness. Like 
most of the gastric lesions, it is oftener present in cases which 
terminate early, than those which are prolonged. 

Louis has taken great pains to ascertain the relationship, if 
any such exists, between these various pathological states of the 
gastric mucous membrane, and the gastric symptoms. The result 
of his inquiries is this : that in a considerable number of cases 
the several lesions, separately or combined, are found after death, 
when there had been no gastric indications of their presence 
during life ; and that epigastric distress, either alone, or with 
nausea, not unfrequently has occurred in cases where the mucous 
membrane of the stomach was found in a healthy condition. All 
the cases, however, in which there was epigastric distress, ac- 
companied by repeated vomiting of bile, exhibited more or less 
extensive disease of the membrane. 1 So far as the absence of 
any constant relationship between the lesions of the stomach and 
the gastric symptoms is concerned, the conclusions of Louis are 
abundantly sustained by the researches of Chomel. 2 

Sec. III. — Small Intestines. In all cases of typhoid fever, 
there is lesion of the small intestines. This lesion is peculiar. It 
is found in no other disease. It is generally extensive. Consti- 
tuting, as this lesion does, the characteristic, and, of course, the 
most interesting and important pathological element of typhoid 
fever, I shall describe it with all possible accuracy and complete- 
ness. Before proceeding, however, to do this, I will more briefly 

1 Lewis's Researches on Typhoid Fever, vol.-i. p. 457, et seq., 2d ed. 

2 Lecras de Clinique Medicale. Par A. F. Chomei, p. 247, et seq. 



LESIONS. — SMALL INTESTINES. 93 

enumerate certain other occasional changes that are found in the 
small intestines. 

The duodenum is not often the seat of any very considerable 
disease. Not unfrequently, it is entirely natural ; at other times 
the mucous membrane is morbidly red, softened, and, very 
rarely, the seat of a small number of minute, superficial ulcera- 
tions. 

The small intestines are moderately distended with flatus, in a 
few cases. Their contents consist, commonly, of a considerable 
quantity of mucus, especially in the upper portion, and of liquid 
bilious matter, of a light yellow or orange color, sometimes 
tinged with red. In cases where there has been hemorrhage 
from the bowels, blood, either coagulated or dark colored, and 
grumous, is found in the intestines. 

In many of these same cases, and in some others where there 
has been no hemorrhage, and where no blood is found in the in- 
testines, the mucous membrane is the seat of sanguineous infiltra- 
tion. This condition has been particularly described by Chomel. 
I have seen it more extensive, and more strongly marked in two 
cases of death from acute jaundice, in both of which there were 
hemorrhagic discharges from the bowels, than in typhoid fever. 
It may exist to the extent of only a few inches, or of several feet. 
It is generally continuous, not in patches or zones. The color of 
the membrane ranges from a rose to a very dark red, and it lias 
a peculiarly brilliant and trembling or quivering appearance, like 
jelly. Chomel found this lesion in seven of forty-two cases. He 
is very confident that it is intimately connected with hemorrhage 
from that portion of the membrane which it occupies. 1 

The mucous membrane, exclusive of the elliptical plates and 
the isolated follicles, is, in a majority of cases, more or less changed 
in color. In many, it is preternaturally red. This redness is 
sometimes continuous, and extends through a large portion of the 
intestinal tract ; at other times, and more frequently, it exists in 
patches or zones. Occasionally, the color is grayish; this is par- 
ticularly the case when the disease has been protracted to a late 
period. 

The consistence of the membrane, like its color, is found, in a 
moderate proportion of cases, quite natural. Oftener, however, it 

1 Le9ons de Clinique Medicale. Par A. F. Chomel, p. 252, ct scq. 



94 TYPHOID FEVER. 

is more or less diminished ; sometimes so much so as to resemble 
an unorganized pulp, spread, like a layer of paste, over the sub- 
jacent tissue. This softening is in some cases quite simple; that 
is, it is not connected with any other appreciable alteration. In 
others, the membrane is, at the same time, reddened or thickened, 
or both. It is the opinion of Louis, that these two forms of soft- 
ening are unlike in their character and causes. The latter he 
considers to be inflammatory ; the former he thinks may depend 
on different causes, but that it is not the result of inflammation. 
In a part, at least, of the cases, he is inclined to regard it as the 
result of a post-mortem or cadaveric change. 

The invariable and characteristic lesion found in the small in- 
testines, to which allusion has been made, consists in alterations, 
differing somewhat in different cases, of the elliptical plates, or 
Peyers glands. The condition in which these bodies are found 
varies with the duration of the disease, with the distance of the 
plates themselves from the ileo-coecal valve, and with other cir- 
cumstances, the nature of which is unknown. Without entering 
into so minute and elaborate a description of the several forms 
of this lesion as has been very properly given in the original 
researches of Louis and Chomel, I shall enumerate the principal 
and more striking varieties. 

In a small proportion of cases, consisting of those which termi- 
nate early, the elliptical plates, together with the subjacent cel- 
lular tissue, are merely increased in thickness, with redness and 
softening. This increase of thickness is such, that the edges of 
the plates project to a distance of from one to two or three lines 
above the surrounding mucous membrane. Sometimes, the hy- 
pertrophy of the plates and of the subjacent tissue is quite simple, 
the color and consistence of the membrane remaining unaltered. 
This simplest form of the lesion, that I am now describing, like 
all the others, which are more complex, is invariably found most 
advanced, and most strongly marked, at the lower extremity of 
the ileum. Each successive plate, as we go upward along the 
intestinal tract, from the ileo-coecal valve, is less and less pro- 
foundly altered, till we arrive at those which are in a natural 
condition. The number of plates, thus changed, is very various; 
sometimes extending to fifteen or twenty, and at others limited 
to one or two, and these always in the immediate neighborhood 
of the ileo-coecal valve. Louis says that, in two-thirds of the 



LESIONS. — SMALL INTESTINES. 95 

cases, the number of plates, more or less altered, is from twelve 
to forty. 

The surfaces of the thickened plates frequently present a granu- 
lar or finely mamellonated appearance, occasioned by an enlarge- 
ment of the gray orifices of the cryptse, which go to make up the 
plates. This condition becomes very manifest when the gland is 
detached from its subjacent tissue, and held between the eye and 
the light. At other times, the surface of the thickened membrane, 
corresponding to the plates, is quite smooth and level. 

In a great majority of cases, the plates, instead of being merely 
thickened, with or without redness and softening, are more or less 
extensively the seat of ulcerations. These ulcerations vary very 
much in size and in number. It frequently happens, for instance, 
that in proceeding from above downwards, in our examination, 
after having passed over several plates, simply thickened, we 
come to one of them in which there is a single, circumscribed 
ulceration, with perpendicular edges, extending more or less 
deeply into the thickened tissues. As we go on towards the ter- 
mination of the intestine, the ulcerations become more and more 
numerous and extensive, till at last, for several inches next to 
the valve, the plates are entirely destroyed, and we find only 
ulcerations, corresponding to their sizes and shapes, occupying 
their places. 

These intestinal ulcerations are commonly more or less regu- 
larly rounded or oval in their shape. Sometimes, however, their 
borders are irregularly jagged, and angular. So their edges are, 
in most cases, pretty regularly perpendicular and smooth, but 
sometimes they are ragged and shreddy. The bottoms of the 
ulcerations vary, of course, with their depths. They consist, 
sometimes, of the cellular tissue immediately under the mucous 
membrane; sometimes of the muscular coat, and sometimes of 
the peritoneal covering. Occasionally, this covering itself gives 
way, perforation takes place, and the contents of the intestine 
are discharged into the cavity of the peritoneum. Louis found 
this lesion in eight of fifty-five cases. Chomel quotes two in- 
stances of its occurrence, in his clinique at the Hotel Dieu ; in 
one of which, however, the perforation took place in the large 
intestine. The perforation is usually single, small in diameter, 
and near to the termination of the ileum. In one of three cases, 
mentioned by Dr. Hale, it was at the distance of forty-four 



96 TYPHOID FEVER. 

inches from the ileo-coecal valve. It generally takes place at a 
late period of the disease. Perforation occurred in three of Dr. 
Jenner's twenty-three cases, respectively on the seventeenth, 
thirty-first, and forty-second day of disease. " The perforation 
in all three took place through the floor of an ulcer seated on 
one of the agminated glands. In two of the three, perforation 
occurred in the lower nine inches of the ileum ; in one, three 
feet above the ileo-coecal valve. In two of the three, the coats 
of the intestine were destroyed through their whole thickness, at 
another spot from that at which the perforation, which proved 
fatal, took place ; but the contents of the bowel had been pre- 
vented escaping through the aperture first formed by adhesion, 
in the one case, to the fundus of the uterus, and in the other, to 
a fold of the intestine. It will be observed that, in one of the 
three cases certainly, the fatal perforation took place after the 
termination of the fever." 1 It is a very singular fact, that this 
fatal accident commonly occurs in the course of very mild, or 
almost entirely latent, forms of the fever. This was the case in ten 
of twelve instances cited by Chomel. Chomel suggests that the 
distension of the intestines by gas may frequently be the imme- 
diate cause of perforation. This seems hardly probable, since 
the greatest distension is usually confined to the large intestine, 
while perforation is most frequent in the small. It has occurred 
to me that the frequency of the accident in the mildest^ and in 
some degree, latent form of the disease, might possibly be occa- 
sioned by mechanical causes, especially by efforts of the patient 
while standing and walking. 

This accident is much less common in children than in adults. 
Taupin met with it only twice, in one hundred and twenty-one 
cases ; and Barthez and Rilliet only once, in one hundred and 
eleven cases. 

There is another peculiar appearance of the diseased plates, 
which is found in a certain proportion of cases ; according to 
Louis, in somewhat less than one-third. This seems to consist 
in a morbid change or transformation of the submucous cellular 
tissue. Instead of being simply hypertrophic, with or without 
redness and softening, as in the cases already described, there is 
deposited in the tissue a substance of a yellowish color, destitute 

1 Jenner, &c, p. 61. 



LESIONS. — SMALL INTESTINES. 97 

of any traces of organization, presenting a surface somewhat 
glossy when cut, and about as hard and friable as crude tubercle. 
The term typhous matter has been given to this morbid deposit. 
This peculiar condition was observed in several subjects, during 
the grave epidemic of 1833-4, in the city of Lowell ; and in 
accordance with the fact, previously noticed by Louis, it was most 
frequent and striking in cases which terminated quite early. 
This would seem to indicate that the alteration in question is 
connected with the more severe and rapid forms of the disease. 

M. Forget describes the lesion of Peyer's glands under six 
different forms. The first of these he calls the form point UUe, 
the punctated or pointed form. It was first described by Roede- 
rer and Wagler ; and its appearance compared with that of the 
beard newly shaven. This condition of the glands has been 
noticed by Andral, Chomel, Forget, and others ; but there is no 
satisfactory evidence that it is especially connected with typhoid 
fever. It is doubted even whether the appearance is really 
pathological. It is not often met with. 

The second form is the reticulated. The glands are rarely 
thickened ; their color varies from that of a grayish red to a deep 
red, and their consistence is greatly diminished. The substance 
of the glands presents the appearance of a pretty regular net- 
work, resembling somewhat the pulp of a cherry. This appear- 
ance is more striking when the glands are examined under water. 
It has been suggested that this form may be constituted by the 
first, or at least by the earlier, changes which take place in the 
glands. 

The third is the honey-comb form. It is the hard form of 
Louis, and has been already described. 

The fourth form is the pustular. The peculiarity of this form 
consists simply in the size and shape of the altered glands. 
These are small and circular, thus occasioning the pustular 
appearance. Cruveilhier and Forget think that this pustular 
form is generally connected with very grave and rapidly fatal 
cases of the disease. 

The next form is the gangrenous. Forget says it is always 

the result of the hard or honey-comb form. The substance of 

the gland loses its vitality ; it becomes of a yellowish or greenish 

color ; its edges, growing ragged and shreddv, are detached : and 

7 



98 TYPHOID FEVER. 

finally the entire gland is thrown off, leaving the subjacent mus- 
cular or serous tissue exposed. 

The sixth is the ulcerated form. This has been already de- 
scribed with a sufficient degree of minuteness. 

These lesions of the follicles, both isolated and agminated, can 
very generally be recognized through the outer or peritoneal 
coat of the intestine. This coat, at the points corresponding to 
the thickened and ulcerated glands, is frequently of a reddish or 
bluish color, sometimes injected, or even covered with a layer of 
fibrine ; and the thickened glands can, in most cases, be distinctly 
felt by the thumb and finger, as chancres, says Forget, can be 
felt through the prepuce. 

Dr. Jenner, after a careful examination and analysis of these 
lesions in twenty-three cases, sums up the results in the following 
conclusions : — 

"1. That ulceration of the solitary and agminated glands may 
commence in two modes ; on the one hand, by softening of the 
mucous membrane, abrasion of the extremely softened superficial 
tissue, and then enlargement of the breach of continuity thus 
formed, in depth and extent, by simple ulceration ; on the other, 
by sloughing of a portion of the submucous tissue containing the 
before-described deposit, and of the mucous membrane over it, 
and then extension of the ulcer in breadth and width, by the 
separation of minute sloughs from the edges of the breach of 
continuity, left after the separation of the slough first formed. 

"2. That when the whole of the deposit has sloughed out, no 
fresh deposit is formed ; and that, consequently, as the whole of 
that deposit is seated in the submucous tissue, destruction of the 
muscular fibres of the intestine must be the result of simple 
ulceration. 

"3. That resolution of the disease affecting the patches may in 
some cases occur before ulceration has taken place. 

"4. That ulcers of considerable size may heal. 

"5. That no contraction follows, within a short period, the 
healing of the ulcers. 

" 6. That ulcers dependent for their origin on the presence in 
the system of the fever poison, may, after the fever has run its 
course, continue to spread, retard recovery, and even cause death 
by perforation. 

"7. That while some of the ulcers are undergoing the healing 



LESIONS. — SMALL INTESTINES. — PETER'S GLANDS. 99 

process, others may be spreading ; or, as Rokitansky says, may 
pass into the state of atonic ulcers. 

" These atonic or simple ulcers, left after the termination of 
the fever, are a frequent cause of lengthened duration of illness 
in cases of typhoid fever." 1 

I have spoken of this lesion of the glands of Peyer, in some 
of the forms which have now been enumerated, as invariably 
present in typhoid fever. I have also spoken of it as charac- 
teristic of this disease. The question of the absoluteness of this 
pathological law — of the constancy of the relationship between 
the intestinal lesion and the group of symptoms by which we 
recognize the disease, during life — will be further considered, 
when I come to treat of the diagnosis of typhoid fever. 

The only remaining alterations found in the small intestine, of 
which it is necessary to speak, are those of the isolated follicles, 
or Brunner's glands. Louis found them more or less diseased, in 
twelve of forty-six cases. They are subject to the same changes 
which have just been described, in connection with the elliptical 
plates, and, like the latter, they are most numerously and most 
profoundly altered, in proportion to their proximity to the ileo- 
ccecal valve. 

In this disease, as in most others, it sometimes happens that 
death takes place, unexpectedly, from unknown causes, or from 
indiscretions in diet and regimen, after the establishment of con- 
valescence. These occurrences have enabled us to ascertain the 
appearances of the diseased glands, during their march towards 
their original, healthy condition. The deep red tint, character- 
istic of acute inflammation, is found, in these cases, to have given 
place to various shades of gray, ash color, brown, and blue. The 
edges of the ulcerations, if such have existed, are smooth and 
flattened, passing off imperceptibly, each way, into the bottoms 
of the ulcers, and into the adjacent healthy membrane. These 
cicatrizing ulcers are always confined to the lower portion of the 
intestine. Of forty-two cases, Chomel found eleven, in which 
there was either partial or complete cicatrization of the ulcerated 
glands ; and in all these, the cicatrization was limited to the last 
six or eight inches of the ileum. It would seem to be very 
certain that the process of restoration in the diseased glands 

1 Jenner, &c., p. 60. 



100 TYPHOID FEVER. 

follows the same march, from the ileo-ccecal valve upwards, which 
is so evidently followed in the development of the lesions them- 
selves. 

It is the opinion of Chomel that, where the cicatrization of the 
ulcers is complete, all traces of the lesion finally disappear. He 
says that, in the numerous autopsies at the H6tel Dieu, in many 
of which there was good reason to think that the subjects had 
formerly had typhoid fever, there were never found any obvious 
proofs of old ulcerations, in the form of remaining cicatrices. It 
is reasonable to suppose that, in many cases, especially in mild 
forms of the disease, the local lesion terminates in resolution, 
there having been no loss of substance, either by ulceration, or 
gangrene. 

Sec. IV. — Large Intestine. There are only two alterations 
of the, large intestine, especially connected with typhoid fever. 
These are its distension by flatus and ulcerations. The flatulent 
distension is present in a large proportion of cases. It is some- 
times very great, pushing up the liver, the stomach, and the dia- 
phragm much beyond their usual positions, and accounting for 
the extreme tympanitic enlargement of the abdomen during life. 
Louis found this meteorism of the large intestine most frequently 
present and most strongly marked in cases which terminated 
between the twentieth and thirtieth day. 

Ulcerations are found in about one-third of the cases. They 
were present in twenty-three of seventy-four examinations, made 
by Louis and Barth. They are generally small in size, more or 
less regularly rounded, not very numerous, more superficial than 
those of the small intestines, and occupying, most frequently, the 
coecum, though not confined to this portion of the large intestine. 
This lesion is most common in cases terminating late in the dis- 
ease. In a small number of instances, the sub-mucous cellular 
substance of the isolated follicles is found to have undergone the 
same yellowish transformation that has already been spoken of 
as occurring in the elliptical plates. 

The mucous membrane of the large intestines is sometimes 
healthy throughout. At others, it is reddened, or thickened, or 
diminished in consistence. There is nothing, however, in these 
last-mentioned alterations, in any way peculiar to typhoid fever; 
since they are found as frequently in many other acute diseases 



LESIONS. — LARGE INTESTINES. — LYMPHATIC GLANDS. 101 

as in this. The contents of this portion of the alimentary canal 
are usually thin, and of a yellow or greenish color. 

As to the relation between the intestinal lesions, on the one 
hand, and the various abdominal symptoms on the other, I have 
but little to say. It would be unreasonable to suppose that such 
a relation does not exist. There can be no doubt that the 
diarrhoea and the abdominal pains are connected with the differ- 
ent lesions of the intestinal canal. It is, nevertheless, sufficiently 
evident that this relation is far from being constant and inva- 
riable. In this, as in almost all other diseases, the violence of 
the symptoms, the perturbations and perversions in the functions 
of the disordered organs, are not to be measured, exclusively, by 
the appreciable pathological alterations which may exist in the 
organs themselves. Other elements and other influences, many 
of them obscure and difficult to seize and to estimate, are con- 
cerned in the production of the symptoms. We thus find in 
typhoid fever that, although there may be a general relationship 
between the abdominal symptoms and the intestinal lesions, 
sometimes the lesions are almost entirely latent; they are not 
revealed by any characteristic symptom during life. Occasionally, 
extensive ulceration of the elliptical plates, with changes of the 
mucous membrane, may exist without giving rise to much diarrhoea 
or to any other prominent abdominal symptom. 

Sec. V. — Lymphatic Glands. The glands of the mesentery 
are always found more or less changed ; according to their posi- 
tion, and according to the period at which the disease has termi- 
nated. Where death takes place before the expiration of the 
third week, they are increased in volume, diminished in consist- 
ence, and of a rosy, or red, color. If life is prolonged beyond 
this period, the volume is found more nearly natural, the soften- 
ing is less marked, and the red color is supplanted by various 
shades of gray, and violet. In some of them, there are found 
small yellow points of a purulent deposition. The diseased glands 
correspond, very nearly, to the altered elliptical plates ; those near- 
est the ileo-coecal valve being most changed in their appearance. 
In a few instances, the glands are moderately enlarged, softened, 
and reddened, opposite the upper plates of the intestine, which 
continue healthy. 

The glands of the meso-colon are also affected in a similar 



102 TYPHOID FEVER. 

manner, but less extensively and less constantly. The same ob- 
servation, with the same qualification, is true of the other lymph- 
atic glands of the body. It is also true that these glands are 
rarely changed from their healthy state in any other acute disease. 

Sec. VI. — Spleen. The spleen is almost always more or less 
altered in its appearance. The most constant change consists in 
an augmentation of its volume. In many cases, it is three or 
four times as large as it is in its natural state. It is, also, very 
generally diminished in consistence. This softening is sometimes 
extreme, so that the parenchyma of the organ is reduced almost 
to an inorganic, pulpy mass. The increased size of the spleen, 
and its softening, frequently exist together, but not always. The 
cases in which this happens most commonly, and in which the 
two lesions are strongly marked, are those terminating most 
rapidly. The color of the spleen is very often changed from its 
healthy appearance, though not so uniformly as its volume and 
consistence. It is generally darker than natural, of a deep, 
bluish brown, and sometimes almost black. These changes of 
volume, consistence, and color generally extend uniformly 
throughout the whole substance of the spleen. Louis found this 
organ in its natural condition, only four times in forty-six exami- 
nations. All the alterations to which it is subject are most 
strongly marked in those cases which terminate before the thir- 
tieth day. 

I have avoided, for the most part, the elaborate discussion of 
questions relating to the nature and causes of the various lesions 
which are found in typhoid fever. It may be well, however, to 
observe here that these alterations of the spleen can hardly be 
attributed to any inflammatory action. The reasons adduced by 
Louis for this opinion seem to me to be sufficiently satisfactory. 
Pus, the most unequivocal evidence of inflammation, is never 
found ; the serous envelope of the spleen is unaltered ; and the 
softening and enlargement affect uniformly the whole substance 
of the organ ; which, so far as all analogies enable us to decide, 
would not be the case, if these lesions were the result of inflam- 
matory action. In the present state of our knowledge, it is 
enough, perhaps, to say, that these alterations of the spleen, in 
typhoid, as well as in other fevers hereafter to be described, de- 
pend upon some special and peculiar cause connected with the 



LESIONS. — LIVER. — PANCREAS. 103 

diseases in which they occur, the nature and operation of which 
are unknown to us; and further, that the lesions seem to be asso- 
ciated with that pathological element, so obscure in its nature and 
causes, but so extensive and fatal in its results, to which the term 
congestion has been applied ; and not with that other element, to 
which the term inflammation has been applied. 

Sec. VII. — Liver. The only alteration of any considerable 
frequency, in the liver, consists of softening. This existed in 
about one-half of Louis's cases; but, inasmuch as it was found 
oftenest during the warm season, it may be that, to a considera- 
ble extent, at least, it is a cadaveric phenomenon, resulting from 
commencing decomposition. In a certain proportion of cases, 
the color of the liver is paler than natural, and it is less filled 
with fluids ; less frequently, it is darkened and reddish, and mode- 
rately engorged with blood. Andral found the liver almost con- 
stantly healthy. 1 

There is no constant or uniform alteration in the qualities of 
the bile contained in the gall-bladder. Oftentimes, it is found 
reddish, greenish, and abundant ; at others, it is darker, of va- 
rious shades, less liquid, viscid, and less abundant. Occasionally, 
the mucous membrane, lining the gall-bladder, is manifestly in- 
flamed, and the bladder contains pus. There is nothing in the 
condition of the liver, or of its secretion, at all peculiar to ty- 
phoid fever. 

Sec. VIII. — Pancreas ; Salivary Glands ; Urinary Appara- 
tus ; and Sexual Organs. These several parts are generally 
found in a healthy state, and the occasional lesions which they 
exhibit are such as occur in other acute diseases. 

The accurate and extensive researches of Rilliet and Taupin 
have shown that the same anatomical lesions are found in pa- 
tients under fifteen years of age as in adults. The differences 
in this respect between the two classes of cases are too few and 
unimportant to make it worth while to notice them in detail. 
The intestinal ulcerations seem to be somewhat less numerous 
and extensive than in adults; and a little later, perhaps, in their 
occurrence. The yellow, hard, friable matter is rarely met with. 

1 Andral's Clinique Medicale, vol. iii. p. 579. 



104 TYPHOID FEVEK. 

ARTICLE Y. 

GENERAL REMARKS. 

Such are the conditions of the several organs and tissues of 
the body in typhoid fever. It will be seen, from the detailed 
descriptions of these organs and tissues which has just been 
given, that the lesions in this disease are numerous and profound. 
Its pathological anatomy corresponds, in complexity, variety, and 
extent, to its symptomatology. There are, indeed, few if any 
diseases of an acute character and of common occurrence, in 
which this complexity, variety, and extent of symptoms and 
pathology constitute so prominent and so striking a feature as 
in this. 

Some of the lesions, as has already been said, are more or less 
accidental ; that is, they do not necessarily constitute any part of 
the pathological anatomy of the disease.' They are not constantly 
present. Many of these, however, such as the changes in the 
mucous membrane of the stomach, and the alterations of the 
spleen, are of very frequent occurrence, and, we have good rea- 
son to believe, play generally an important part in the pathology 
of the disease. Other lesions are not accidental, but essential ; 
necessary to the disease. They always enter into its composition. 
They make up one of its constituent elements. They are inva- 
riably present. This is the case with the alteration of the ellip- 
tical plates of the small intestine, and the lymphatic glands of 
the mesentery, corresponding to these altered plates. 

The real and relative importance of the several lesions, acci- 
dental and essential, is a question, in the actual state of our 
knowledge, not "susceptible of absolute and positive settlement. 
It is a very natural and philosophical conclusion, perhaps, that 
the essential and constant lesions are more important than those 
of an opposite character. This is true, of course, so far as diag- 
nosis is concerned ; so far as the fixing and identification of the 
specific disease is concerned ; but it is very questionable whether 
these lesions exert a more powerful influence upon the rapidity 
and the danger of the disease than some of the others. It seems, 
indeed, very probable that, in many cases, life is destroyed, or 
the disease is rendered dangerous and severe, by the successive 



LESIONS. — GENERAL REMARKS. 105 

development of these secondary alterations, rather than by the 
extent and gravity of the essential lesions alone. 

The order of succession in which the several lesions commence 
and are developed is also a matter not susceptible of very 
rigorous demonstration. Death almost never takes place, in the 
disease, before the termination of the first week, and not often so 
early as this. Still, a careful study and comparison of the patho- 
logical appearances which are presented incases of differing dura- 
tions will enable us to arrive at a reasonably certain approxima- 
tion to the truth. There can be but little doubt, I think, that 
one of the first, probably the first pathological alteration which 
takes place in the solids, consists in the tumefaction of the ellip- 
tical plate, or plates, nearest to the ileo-ccecal valve. This tume- 
faction is accompanied or followed by other changes — an afflux 
of fluids, softening of the mucous coat, the hard, yellow typhous 
deposit in the sub-mucous tissue, and, finally, by ulceration ; and 
these several lesions taking place, first in the plates nearest to 
the ileo-ccecal valve, gradually and successively extend to those 
which are farther removed from it. Contemporaneous, probably, 
or nearly so, with these alterations, are the reddening, enlarge- 
ment, and softening of the mesenteric glands. The enlargement 
of the spleen, and the diminution of its consistence, occur, also, 
there is good reason to think, in the early stages of the disease ; 
and the same thing is probably true, though less constantly, per- 
haps, of the softening of other organs. The various pathological 
changes, which are found in the gastro-intestinal mucous mem- 
brane, begin and are developed, it would seem, at uncertain and 
indefinite periods, during the progress of the disease. 

As to the relation which exists between these appreciable le- 
sions — one or many of them — and the disease itself, if we may 
so speak, I have but little to say. This is a question which is 
wholly theoretical in its character. Its settlement, by different 
individuals, will depend entirely upon the mode of interpreting 
the phenomena of typhoid fever, and the relations of these pheno- 
mena which they may choose to adopt. One thing, however, we 
may say, and that with great confidence, and without any quali- 
fication; to wit, that typhoid fever is not a gastro-enteritis. It 
may, correctly enough, be called a peculiar enteritis, or a dothinen- 
teritis, but not a g astro-enteritis ; and this, for reasons sufficiently 
obvious. I do not think, however, that we are justified in refer- 



106 TYPHOID FEVER. 

ring typhoid fever, considered as a disease — as an integral, though 
complex, pathological condition, and process or series of processes 
— to this single local lesion of the intestines. I do not think 
that we are justified in considering the latter as the exclusive 
origin and cause of the former, as we consider acute inflammation 
of the mucous membrane of the large intestines the cause of that 
other disease — that other integral pathological condition and pro- 
cess, or series of processes — which we call dysentery. The most 
striking analogies are all against this interpretation. It seems to 
me much more satisfactory and philosophical, much more in ac- 
cordance with what is seen in many other diseases, to look upon 
the lesion of the elliptical plates, not as the local cause of all the 
other appreciable phenomena of typhoid fever, but as constitut- 
ing one of the pathological elements, in a very obscure and com- 
plex disease; all which elements, and this quite as much as the 
others, are themselves the result of some morbific agent, or influ- 
ence, or process, the nature, sources, and operation of which are 
wholly unknown to us. The lesion of the elliptical plates seems 
to me to bear somewhat the same relation to typhoid fever, con- 
sidered as a disease, as that which their several characteristic 
eruptions bear to measles, scarlatina, and smallpox. In none of 
these, have we any right to regard the cutaneous eruptions as 
the -causes of the symptoms, and of the other various phenomena, 
which go to make up the several diseases themselves. I shall 
have occasion to refer to this subject hereafter. 



107 



CHAPTER IV. 

CAUSES. 

The only causes of typhoid fever, the influence of which ha3 
been at all positively and accurately ascertained, are these three, 
to wit — age ; recent residence in a given place ; and contagion. 
In using the word cause here, I mean merely to express by it 
some of those circumstances or conditions amidst which the dis- 
ease under consideration most frequently occurs. The nature 
and essence of the actual, producing, efficient cause of typhoid 
fever, as of most other diseases, are entirely unknown to us. 

Sec. I. — Locality. Typhoid fever is, evidently, a disease of 
very extensive geographical prevalence. "We have not the means 
of ascertaining its limits, but there is good ground, I think, for 
believing that these limits are wider than those which circum- 
scribe the prevalence of any other strictly idiopathic, non-eruptive 
fever. It is the common fever of the Eastern States. It is ques- 
tionable, indeed, whether this section of the country is the seat of 
any other fever, unless it be an occasional sporadic case, or epi- 
demic, of an obscure and doubtful character. The extent of the 
prevalence of typhoid fever, in the New England States, may be 
judged of by the following statistics, derived from the bills of 
mortality for the city of Lowell, for a series of sixteen years, from 
1830 to 1846, inclusive. The entire number of deaths from 
typhoid fever amounted to four hundred and thirty-five. There 
was only one disease which occasioned a larger number, and that 
was consumption. The population of Lowell, during this period, 
increased, pretty regularly, from 6477 to somewhat more than 
20,800. The number of deaths, from typhoid fever, annually, 
varied from five, in the years 1830 and 1831, to forty-four, in 
1839. From 1832 to 1846, the smallest number in any single 
year was sixteen. This was in 1841 ; in the preceding year, it 
was twenty-six ; in the following year, it was forty-three. In 



108 TYPHOID FEVEK. 

1846, the mortality went up to one hundred and one. These 
statements serve to show, at the same time, the importance and 
frequency of the disease, and the variations in the extent of its 
prevalence in different years. 1 It prevails, also, more or less ex- 
tensively, in the Middle and Western States. I have often seen 
it in Kentucky, where it is sometimes called the red tongue fever. 
It is probably less common in those portions of the United States 
which are visited by the various forms of intermittent and remit- 
tent fever, than in those which are exempt from these diseases ; 
although more, extensive and accurate observations than have yet 
been made are necessary to settle this point. Now that the 
means for correct and positive diagnosis of the several distinct 
fevers of our country are becoming more and more generally dif- 
fused, there is reason to hope that this, as well as some other 
circumstances in the natural history of typhoid fever, will soon 
be satisfactorily established. 

In December, 1846, I addressed letters to the editors of the 
medical journals, published in the Southern and Western States, 
inquiring particularly as to the existence, in their respective 
neighborhoods and regions, of typhoid fever. These letters have 
been promptly and kindly noticed, and they demonstrate very 
conclusively the prevalence, more or less extensive, throughout 
many portions of the Southern and Western States, of genuine 
typhoid fever, its symptoms and lesions corresponding exactly to 
the common continued fever of France and New England. The 
interest attaching to this subject induces me to make a few ex- 
tracts from this correspondence. 

Dr. Mattingly, of Bardstown, Kentucky, says that typhoid 
fever prevailed extensively in that town during the fall and winter 
of 1846. He enumerates the following phenomena as very con- 
stantly present in cases of moderate severity. " Chills; increased 
local or general heat; accelerated pulse, generally about 100; loss 
of appetite ; muscular debility ; more or less diarrhoea ; pains in 
the bowels ; dulness of the intellect ; more or less delirium ; fre- 
quent epistaxis ; dry, brown, or red tongue, trembling, and with 
difficulty put out of the mouth ; rose-colored spots, or typhoid 
eruption ; twitching of the tendons ; a purplish flush on one side 
of the face, passing over to the other in the course of two or three 

1 An Address before the Mass. Med. Soc. By John 0. Green, M. D. 



CAUSES. — LOCALITY. 109 

hours ; a greater or less degree of tympanites ; somnolence, or 
watchfulness ; ringing in the ears, or deafness ; one or two exa- 
cerbations of fever every day, constantly in the evening, some- 
times in the forenoon. These symptoms come on gradually, in- 
creasing in violence from day to day, for ten or twelve days, when, 
after remaining about at a stand for a few days, they gradu- 
ally give way, and one by one pass off, till convalescence takes 
place." No one will doubt, I take it, the genuineness of the dis- 
ease thus described. Dr. M. treated, during the season, fifty- 
three cases. Of these, twenty-six were between fourteen and 
twenty years of age ; eighteen, between twenty and twenty-five ; 
and nine, between twenty-five and thirty. The average age was 
nineteen years and a half, nearly. There was hemorrhage from 
the bowels in nine cases. Death took place in five cases. There 
was one autopsy, showing ulceration of the elliptical plates, and 
redness and enlargement of the mesenteric glands. 

Dr. Sutton, of Georgetown, saw in his own town and neighbor- 
hood, during the year 1846, forty-three cases. He mentions a 
few trifling differences between his cases, and the disease as de- 
scribed in my book, but none of any importance. He made two 
autopsies, both of which exhibited the intestinal and mesenteric 
lesion. 

Dr. Wooten, of Lowndesboro', Alabama, says : " There are 
physicians in our State who contend that we have no fevers except 
those of a remittent or intermittent type. But my experience 
justifies me in declaring this to be an error. Typhoid fever 
does exist here. It appears at all seasons of the year ; but I 
think it is most common in spring and early summer. Its occur- 
rence is far more frequent of late years than formerly. In 1836, 
I saw but one case of it. In 1837, I had a very serious attack 
of it myself; I was seen by some half dozen experienced physi- 
cians, all of whom spoke of it as a very rare case. It has 
gradually grown more and more prevalent, until it is now looked 
upon as a rather common disease. It is unnecessary to describe 
the symptoms of this fever. It is sufficient to say that they are 
those described by you under the head of Typhoid Fever ; and 
that it is unquestionably the disease for which you inquire." 

I have a sensible letter from Dr. Core, who practises in "Wil- 
liamson Co., Tennessee. There is one locality in his neighbor- 
hood, which, from the extensive prevalence of typhoid fever. 



110 TYPHOID FEVER. 

within the last few years, has received the name of typhoid 
bottom. 

Dr. Linton, editor of the St. Louis Medical and Surgical Jour- 
nal^ in a short but excellent letter, says: " The fever, or variety 
of fever, of which you speak, prevails here as in Kentucky, though 
I think it is not, either here or in that State, generally recognized 
as the typhoid fever. It is sometimes called winter fever, or 
nervous fever, and sometimes it is not dignified with any specific 
name. But of the fact, that we have here a continued fever, 
commencing with chilly sensations, headache, and general mal- 
aise, complicated with diarrhoea, and more or less bronchial irri- 
tation, and exhibiting in its course, in many instances, the rose 
spots, or sudamina, or both, and running a course of*from three 
or four to six or seven weeks, there, can be no doubt I have 
treated several such cases in this city." 

Dr. Leake, of Yazoo city, Mississippi, says the disease has pre- 
vailed more or less extensively, for several years, in his neighbor- 
hood. 

Dr. Coe, of Dekalb Co., Georgia, says, in a letter, dated 
March 17, 1847: "About one year ago, an epidemic prevailed 
very generally over a small extent of country, which I determined 
to be typhoid fever. The section in which it prevailed had been 
previously healthy ; it is elevated, with a poor soil, and has only 
one small stream passing through it. The locality of which I 
speak was about twelve or fifteen miles square, and almost every 
family, and nearly all the members of each family, except old 
persons and young children, were attacked by the fever. It was 
most extensive during May, June, July, and August. The num- 
ber of cases amounted to two hundred. The following were 
amongst the most common symptoms: Chills, more or less 
severe ; headache, with pain in the back ^and limbs, which subsided 
in a few days ; thirst, heat of the skin, acceleration of the pulse, 
and an evening exacerbation; entire loss of appetite; great 
muscular debility ; dulness and confusion of the intellect, passing 
gradually into delirium ; great restlessness, subsiding just before 
day, to some extent, to commence again about breakfast-time; 
twitching of the tendons ; picking at the bedclothes, or at ima- 
ginary objects; occasional epistaxis; ringing or buzzing in the 
ears; a dry, glutinous, cracked, red, or brown, or blackish 
tongue, protruded with trembling; dark, thick sordes on the 



CAUSES. — LOCALITY. Ill 

tectli ; diarrhoea, the stools thin and watery, dark or yellowish, 
sometimes bloody ; tympanitic state of the abdomen ; gurgling 
in the right iliac region on pressure. The disease was confined 
to persons between the ages of ten and forty years. There 
were twenty-two or twenty-three fatal cases." 

Dr. John P. Mettauer describes a continued fever of middle 
and southern Virginia. From 1816 to 1829, he treated more 
than four hundred cases. He says the disease prevailed in three 
forms, to wit — those of synocha, typhoid, and typhus. Dr. 
Mettauer's description of the disease is not sufficiently minute 
and detailed to enable us to judge of the reality of these distinc- 
tions. The probabilities, however, are that the disease was true 
typhoid fever, and nothing else. 1 Dr. Austin Flint, of Buffalo, 
has published an account of the disease, as it prevailed at the little 
settlement of North Boston, in 1843. The disease seems to have 
been introduced by a traveller from Massachusetts. Of forty- 
three persons, constituting the entire population of the village, 
twenty-eight had the fever between October 19 and December 
7. Ten cases terminated fatally. 2 

Dr. Samuel Jackson speaks of its frequent and extensive pre- 
valence in the region of Northumberland, Pennsylvania. 3 

In the statement of deaths in New Orleans, for the last six 
months of the year 1844, forty-four are set down to typhoid fever. 
In the Report of the New Orleans Charity Hospital for 1844, 
ninety-two cases are classed as typhoid fever. 4 I do not know 
how confidently the diagnosis, in these cases, is to be relied upon. 

It would seem that the typhoid is the most common and gene- 
rally diffused fever of the temperate latitudes of the continent of 
Europe. Certainly it is so of France, where it has been most 
extensively and thoroughly studied. It seems to be also the com- 
mon fever of Germany. In vol. xlviii. of the Edinburgh Medical 
and Surgical Journal, there is a notice of this disease, as it is 
described by several writers, prevailing at Brux in Bohemia, 
Dresden, Berlin, and at Stangenrod. Burserius describes the 
disease very fully and accurately, under the title of sloiv nervous 
fever. 5 Louis saw it at Gibraltar in 1828. It occurs with con- 
siderable frequency in the British Islands, although it is not their 

1 Amer. Journ. Med. Sci., July, 1843. 2 Ibid., July, 1845. 

3 Ibid., Oct, 1845. 

< N. 0. Med. Journ., vol. i. pp. 390, 392. * inst. p rac t. Med., vol. i. p. 47?. 



112 TYPHOID FEVER. 

most common form of fever. The means, however, for ascertain- 
ing, with any degree of precision, the actual extent and frequency 
of its prevalence, in the several portions of Great Britain, do not 
exist, for the obvious reason that no distinction has generally 
been made between this disease and the contagious typhus. It 
will probably be found to be of more common occurrence, in cer- 
tain portions of the country, than in others, and at certain seasons 
or periods of time. This subject wilL necessarily come before us 
again in the account which will be given of the investigations that 
have been made, within the last few years, in regard to the iden- 
tity, or the non-identity, of typhus and typhoid fever. -It cannot, 
however, be fully settled, without the aid of observations very 
much more extensive and discriminating than have yet been 
made. In the mean time, we can only approximate to the real 
truth in regard to the matter. Typhoid fever seems to have been 
of common occurrence at Dublin, from 1826 to 1829. Dr. Ken- 
nedy states that he found the elliptical patches more or less dis- 
eased in a large proportion of cases during this period, present- 
ing a striking contrast, in this respect, to the contagious typhus 
of 1837. Dr. Stokes also says : " In the epidemic of 1826 and 
1827, we observed the follicular ulceration, in the greater num- 
ber of cases. In many instances, perforation took place, and the 
whole group of vital and cadaveric phenomena corresponded 
almost exactly to the dothinenteric affection of the French au- 
thors." 1 In Edinburgh, Dr. Christison says: "The intestinal 
affection has repeatedly presented itself in groups ; the eonstitutio 
dothinenterica, to speak in nosographical language, has repeatedly 
appeared and disappeared, as a subordinate or intercurrent epi- 
demic, in the course of the more general epidemic, typhus." 2 At 
Anstruther, in Fifeshire, only thirty miles distant from Edin- 
burgh, this would seem to constitute, as it does in France and in 
New England, the common form of fever. Mr. John Goodsir, Jr., 
informed his friend, Dr. Reid of Edinburgh, that for five years he 
had attended about one hundred cases of fever, annually, in An- 
struther, and its neighborhood, amongst which there had been 
fifteen deaths. In ten of these, he had succeeded in obtaining 
post-mortem examinations ; and in all of them he had found the 
elliptical plates, and the isolated follicles of the lower portion of 

1 Dunglison's Medical Library. 2 Ibid. 



CAUSES. — LOCALITY. 113 

the ileum, elevated and ulcerated, and the mesenteric glands, 
enlarged and softened. In four cases, perforation of the intestine 
had taken place. From the slight sketch of the symptoms, given 
by Dr. Reid, as well as from the abdominal lesions, there can be 
little doubt, I think, as to the character of the fever. 1 It would 
seem, also, to be very common at Birmingham. Dr. Ward has 
published an account of a fever which prevailed in certain quar- 
ters of that city in the summer of 1837, in all the fatal cases of 
which, the lesion of Peyer's glands is said to have been present. 
Mr. Henry Edmonstone has published, in vol. xix. of the Edin- 
burgh Medical and Surgical Journal, a short account of the pre- 
vailing fever at Newcastle-upon-Tyne, in the years 1821 and 
1822; from which it is quite evident that the fever was typhoid. 
In vol. xli. of the same journal, there is a pretty full and valuable 
history, by Richard Poole, Esq., of what he calls an epidemic 
gastric fever, which prevailed in Limerick garrison, during the 
summer of 1833, and which was clearly typhoid fever. Nearly 
all the most characteristic symptoms of the disease were strongly 
marked. In the same volume, there is another history, by the 
same gentleman, of a similar epidemic, which prevailed at Tem- 
plemore, county Tipperary, Ireland, in the latter part of 1833. 

Dr. Stewart remarks that, during the summer and autumn of 
1836, the cases of typhoid fever received into the Glasgow Fever 
Hospital were numerous ; while from the month of November, in 
that year, at which time both the type and the amount of typhoid 
fever became more formidable, till June, 1838, the period at 
which his connection with the hospital ceased, not more than a 
dozen cases, and these at long intervals, were admitted. 2 Dr. 
Jenner says : " Typhoid fever is a very common disease, especially 
in young persons ; it is the endemic fever of London." 3 

Hillary, in his account of the diseases of Minorca, describes a 
slow nervous fever, which was, very evidently, typhoid. He says : 
" The fever put on and appeared in this warm climate, with all 
the same symptoms as it usually does in England ; and as they 
are accurately described by that learned and able physician Dr. 
Huxham, in the cooler climate of Plymouth. This slow nervous 
fever was certainly infectious, for I observed that many of those 

1 Edin. Med. and Surg. Journal, Oct. 1839. 2 Ibid., Oct. 1840. 

a Medical Times, 8th paper, p. 11. 



114 TYPHOID FEVER. 

who visited, and most of them that attended, the sick in this 
fever, were infected by it, and got the disease, and especially 
those who constantly attended them, and performed the necessary 
offices for the sick." 1 

As to the influence of circumscribed localities upon the preva- 
lence of the disease, very little is known. It is sometimes absent 
from large sections of the country, for a considerable period of 
time. Nathan Smith says that for the first eight years of his 
practice, which was somewhat extensive in the latter part of the 
last century, near the Connecticut River, in New Hampshire, he 
neither saw nor heard of a single case of the disease. Subse- 
quent to that time, for a period of twenty-five years, he " never 
so far lost sight of the disease as to be unable to follow its changes 
from one place to another, and to tell where it was prevailing." 
"It seems to possess," he adds, "a migratory character, and 
travels from place to place ; and after remaining in one village 
for a longer or shorter time, as from one year to two or three, it 
ceases, and appears in another." 2 It prevails often and exten- 
sively in the manufacturing villages of New England. This may, 
perhaps, be sufficiently accounted for by the circumstances favor- 
ing the occurrence of the disease, connected with the population 
of these villages. These are age, duration of residence, and ex- 
posure to contagion. In the city of Lowell, the largest manufac- 
turing place in the Eastern States, containing now, 1852, a 
population of about thirty-five thousand, an unusual proportion 
of whom are between the ages of fifteen and thirty, and very 
many of whom are new residents, the disease has been almost 
constantly present for the last twenty-five years. In some years 
and seasons, it has prevailed much more extensively than in 
others ; and not unfrequently, for considerable periods of time, 
the cases have been occasional and few. It is a very common 
circumstance for it to exist more extensively in certain portions 
of the city than in others. But there is nothing fixed in these 
localities; they are sometimes in one part of the city, and some- 
times in another. Instances have frequently been noticed, also, 
in various parts of the country, in which the disease is confined 
to a single family in a neighborhood. In these cases, several 

1 Rush's Hillary, pp. 30, 44. 

2 Smith's Med. and Surg. Memoirs, p.. 46. 



CAUSES. — LOCALITY. 115 

members of the family are sometimes taken with the disease 
nearly simultaneously ; at others, they are affected in succession, 
one after another, so that the fever may occupy some months in 
passing through the family. Dr. James Jackson, of Boston, no- 
ticed this circumstance, particularly, in a paper in the New Eng- 
land Journal of Medicine and Surgery, for July, 1822. He 
supposes the cause to be in some way connected with the soil of 
the immediate locality, although not at all depending upon any 
filth, or decomposing substances, since no such substances could 
be discovered, and since the houses were often new, clean, in good 
situations, and occupied by families in easy circumstances. He 
expresses his disbelief in the agency of contagion, although he 
says that he has often known the disease to occur in friends, and 
hired nurses, who had gone from other families to attend the sick, 
especially when such persons have remained in the house with the 
diseased subject, for two or three days at least, and generally for 
a longer time. A remarkable example of the obscurity in which 
some of the causes of typhoid fever are enveloped, and of its 
singular and inexplicable connection, at certain times, with cer- 
tain localities, was exhibited during the winter of 1834-5, in the 
city of Lowell. In the course of the winter, there were occa- 
sional cases of the disease, in almost every part of the city, but 
by far the greatest number occurred amongst the female opera- 
tives of a single cotton mill ; and most of these, even, were con- 
fined to two rooms. This mill is situated on a line with five 
others, and in their immediate vicinity. It is about one hundred 
and fifty feet in length, and five stories high ; the rooms occupy- 
ing the whole length and breadth of the mill, with numerous 
windows on every side. The ground room was used for carding, 
and the average number of hands employed in it was thirty-five. 
There ivas not a single case of the disease from this room. The 
second story was used for spinning. Four females employed in it 
went out sick during December ; one on the 8th, 9th, 10th, and 
15th, respectively. The one who left on the 10th died on the 
27th of the same month. The average number employed in this 
room was sixty. The third story was appropriated to weaving, 
and the average number of operatives employed in it was sixty- 
five. Between December 5th, 1834, and January 22d, 1835, 
twenty-six girls left this room ; all of whom, excepting some three 
or four, were ascertained to have had the fever. They left the 



116 TYPHOID FEV^ER. 

mill in the following order : one Dec. 5th, two on the 11th, one 
on the 13th, one on the 18th, two on the 20th, two on the 21st, 
three on the 22d, two on the 23d, one on the 24th, 27th, and 
31st, respectively. One left Jan. 5th, two on the 8th, two on 
the 9th, and one on the 10th, 12th, 21st, and 22d, each. The 
fourth story was used for the same purpose, and had the same 
number of employed hands, as the third. Between Dec. 13th, 
and Jan. 27th, eighteen girls left this room sick. One left Dec. 
13th, one on the 17th, two on the 19th, one each on the 20th, 
22d, and 23d, two on the 24th, and one on the 27th. Three left 
Jan. 1st, and one on the 7th, 9th, 10th, 16th, and 27th, succes- 
sively. From the fifth story, occupied as a weaving-room, and 
having from twenty-five to thirty girls employed in it, there were 
but two sick. One of these left the room Jan. 10th, and the 
other Jan. 17th. 

Thus, of one hundred and thirty females, employed in two 
rooms of the same building, nearly one-third were attacked with 
typhoid fever between the days of Dec. 5th, 1834, and Jan. 27th, 
1835. Of this number, nine died in Lowell. There were also 
two deaths ascertained to have taken place amongst those who 
left the city immediately on leaving the mill. During this 
period, there were a few cases of fever in various other parts of 
the city. Nothing could be discovered about the mill or the two 
weaving-rooms in any way to account for the connection of so 
many cases with this particular mill, and these particular rooms. 
There was but a very small number sick from the neighboring 
mills. The overseer of the room in the third story, where the 
largest number was attacked, informed me that, for nearly five 
years, during which he had had the care of the room, there had 
been amongst those at work in it only three deaths. The 
weather, at the time when the fever began to show itself, was 
extremely cold. There did not seem to be any connection 
between the disease and the situation of the boarding-houses of 
those who suffered from it. These houses accommodated from 
twenty to thirty girls each ; in a few of them, there were two or 
three patients sick at the same time, but in many of them only 
one. 

An instance of this connection of the disease with circumscribed 
localities, somewhat similar to the foregoing, took place in 1835 
at a woollen manufacturing establishment on the Neponset River, 



CAUSES. — LOCALITY. 117 

in Dedham ; a short account of which was published by Dr. Jack- 
son in the Boston Med. and Surg. Journal. On the 11th and 
12th of April, eighteen girls, living in the same house, were 
attacked with typhoid fever; one of whom died. All these girls 
worked in one of two mills, near the house. From the other 
mill, there were no cases ; and neither were there any cases in 
the neighborhood, excepting those in this one boarding-house. 
The entire number of its inmates was fifty-eight. The house had 
been built only eight years; it was clean, and not crowded; and 
no death had ever taken place in it till about a week before the 
appearance of these eighteen cases of fever. On the 5th of April, 
a girl from the same mill with the others died, after an illness of 
nearly three weeks, with what was at first considered by her phy- 
sician, Dr. Spear, as scarlatina; but which he regarded subse- 
quently as typhoid fever. All the females who were attacked on 
the 11th and 12th of April had seen this first patient; some of 
them, however, only after death. In May, another girl had the 
fever ; not an operative in the mill, but a domestic in the boarding- 
house. 

Dr. Wooten, of Lowndesboro', Alabama, in a letter to me upon 
the subject of typhoid fever in his neighborhood, says: " There 
is a circumstance connected with its prevalence here worthy of 
note. We have a high ridge of land, possessing a sandy and 
gravelly soil, which affords many springs of good freestone water, 
and is selected by many planters, who occupy the surrounding 
country, for their residences. This ridge is about six miles long* 
and from one to three miles wide, and at its nearest point about 
three miles from the Alabama River. It is surrounded by 
prairie plantations and prairie sloughs on all sides except that 
towards the river, where it is bordered by a low, pondy, and 
malarial country. In all the surrounding country, intermittent 
and remittent fevers are an annual matter-of-course occurrence, 
whilst the true typhoid is extremely rare, though cases of it do 
sometimes occur. But upon the ridge, where remittents and 
intermittents are of very rare occurrence, the typhoid cases are 
of frequent occurrence, especially during the last few years ; so 
that many planters say they would prefer remaining on their 
plantations, and having their regular turn of chills and fever, to 
residing on the ridge, and risking this sloio fever. 1 " 

There is a pretty common opinion that typhoid fever has a 



118 TYPHOID FEVER. 

tendency to come in and take the place of intermittents and 
remittents, as these diseases, from the effects of cultivation and 
from other causes, diminish and disappear. Dr. Austin Flint, of 
Buffalo, says: "That typhoid fever has, to a great extent, 
superseded the remittent form, has been a matter of frequent 
remark for some time ; and in a brief enumeration of the distinc- 
tive traits of remittent, typhus, and typhoid fever, published by 
us in the first volume of this journal, we mentioned this as a 
sentiment generally entertained by the profession in this region. 
That some allowance is to be made from the fact already referred 
to, that the boundary lines between the two forms are now much 
more clearly drawn, and have been rendered more familiar to 
practitioners, we regard as highly probable ; yet we think there 
cannot be a doubt that a striking change has taken place within 
a few years past, and that typhoid fever, from having been to 
say the least of unfrequent occurrence, has become frequent, and 
is becoming more and more so, remittents diminishing in frequency 
after the same ratio." 1 

These views are corroborated by some conclusions to which 
M. Boudin has recently arrived. He says that there exists an 
antagonism between typhoid fever on the one hand, and inter- 
mittent fever and phthisis on the other. "Those localities," he 
says, "in which the producing cause of endemic intermittents 
thoroughly modifies the constitution, are remarkable for the 
infrequency of pulmonary phthisis and typhoid fever. The 
localities in which phthisis and typhoid fever are particularly 
prevalent are remarkable for the infrequency and mildness of 
intermittent fevers contracted on the spot. The drying up of a 
marsh, or its conversion into a lake, diminishes or prevents 
intermittent fevers, but seems to dispose the organism to a new 
series of diseases, in which pulmonary phthisis and typhoid fever, 
according to the climate, are particularly prominent. After a 
residence in a thoroughly marshy locality, an individual enjoys 
an immunity from typhoid fever, the degree and duration of 
which are in direct proportion to the length and degree of the 
exposure." 

Sec. II. — Season. It is not settled how far typhoid fever oc- 

1 Buffalo Med. Journ., Feb. 1847. 2 London Lancet, March, 1847. 



CAUSES. — LOCALITY. — CONTAGION. 119 

curs, with any degree of uniformity, more frequently in one sea- 
son of the year than in another. The common impression, in 
New England, is, that it prevails oftenest in the autumn. Dr. 
James Jackson says, expressly, that such is the fact ; although he 
admits that it may be seen in any month of the year. Nathan 
Smith docs not speak of its occurrence more frequently at one 
season than at another, and he thinks that he has seen it, not 
only in every month, but in every day of the year. Amongst 
the epidemics mentioned by Gendron, one continued from May 
to October, one from February to May, and one from March to 
January. The most extensive and fatal visitation of the disease, 
in the city of Lowell, took place during the winter and early 
spring. I am very sure, however, that, as a general rule, its 
annual prevalence is greatest in the autumn. In New England, 
it is not unfrequently called the autumnal or fall fever. In the 
Richmond epidemic of 1840, the first case occurred on the 22d of 
August; there were, in August, six cases ; in September, seventeen ; 
in October, ten; in November, six; in December and January, 

1841, each, two; and in February, three — the last case com- 
mencing on the 28th of this month. The disease then disap- 
peared till the 16th of August, 1841, when it returned. There 
were, in August, four cases; in September, six; in October, 
eighteen; in November, seven; in February, 1842, one; in 
March, seven; in April, one ; and in May, two. From May 3d, 

1842, to August 4th, there was no new case. The disease then 
reappeared, and there were, in August, three cases ; in Septem- 
ber, two ; and in October, one. 

I have the following statement from Dr. Gilman Kimball, il- 
lustrating the influence of season upon the prevalence of typhoid 
fever. There were admitted to the Lowell Hospital, during seven 
years, from May 1840, to May 1847, six hundred and forty-five 
patients with typhoid fever. They were distributed amongst the 
twelve months in the following manner, to wit : May, forty-one ; 
June, thirty ; July, forty-seven ; August, eighty-six ; September, 
ninety-two ; October, ninety-eight ; November, sixty ; December, 
forty-eight ; January, thirty-nine ; February, forty-three ; March, 
forty; and April, twenty-one. Two hundred and seventy-six 
cases were admitted during the months of August, September, 
and October. The number of deaths was twenty-nine, giving a 
mortality for the entire period of only one in twenty-two and a 



120 TYPHOID FEVER. 

quarter. The general treatment is negative and expectant ; 
many of the patients taking nothing but gum Arabic and drinks. 
One hundred and eighty-three cases at Strasbourg were dis- 
tributed amongst the four seasons in the following manner, to 
wit: spring, thirty-eight; summer, forty-nine; autumn, sixty; 
winter, thirty-six. 1 

Sec. III. — Contagion. The general opinion has been that 
typhoid fever is not propagated by contagion. Louis, in his first 
edition, published in 1829, says nothing upon this subject. Cho- 
mel, in his Legons de Clinique Medicale, published in 1834, al- 
though he himself was inclined to the opposite opinion, says 
that not more than one physician of a hundred, in France, re- 
garded the disease as contagious. Andral says he never saw any 
evidence of its contagiousness. Dr. James Jackson says, if he 
were to answer from general experience, he should say that in- 
stances occur in which there is much in favor of the doctrine of 
contagion ; but that, in the very great majority of instances, there 
is not any such evidence. He relates some cases, occurring 
amongst the hospital nurses, apparently attributable to conta- 
gion. 2 In 1829, M. Bretonneau read to the Royal Academy of 
Medicine a paper, intended to show that the disease, as it pre- 
vailed in the country, was often transmitted from one individual 
to another. Leuret, about the same time, adopted a similar 
opinion. The subsequent researches of Gendron, Ruef, Putegnat, 
and others have confirmed this opinion, and Louis has adopted 
it in the second edition of his work, published in 1841. Many 
years, however, previous to these publications, Nathan Smith as- 
serted, in the most positive and unqualified terms, the contagious 
character of this disease. His essay was published in 1824. 
"That the typhus fever is contagious," he says, "is a fact so 
evident to those who have seen much of the disease, and who have 
paid attention to the subject, that I should have spared myself 
the trouble of saying anything in regard to it, did I not know 
that there are some physicians in this country who still dispute 
the point ; one which I think can be as fully demonstrated as 
that the measles, smallpox, and other diseases, universally al- 

1 Traite de l'Enterite Folliculeuse. Par C. P. Forget, p. 409. 

2 Report, &c, p. 144. 



CAUSES. — CONTAGION. 121 

lowed to be contagious, are so." 1 Dr. Smith then mentions 
several instances, which had fallen under his own observation, 
where the disease seemed to have been communicated through 
the medium of a contagious principle. From amongst these, I 
select the following. " A young man, a pupil of mine, was at- 
tacked with the typhus fever, from which he recovered with some 
difficulty. Some of his family, who lived about forty miles dis- 
tant, came and took care of him during his sickness. Upon his 
recovery, they returned home in good health, but soon after 
sickened with the same disease, and communicated it to others, 
who had not been exposed in the first instance. From this, it 
spread to numerous other families in the vicinity, who had been 
exposed to the contagion. In the whole town where this oc- 
curred, there had been no case of typhus fever for many years, 
till brought there by the circumstance above related." 

" During the prevalence of the typhus fever in Thetford, Ver- 
mont, a woman went there from Chelsea, about ten miles dis- 
tant, to visit and administer to a sister sick of this disease. 
Upon her return, she was herself attacked by it, and soon after 
died. Others of her family contracted it of her ; and in about 
four weeks there were thirty persons taken down with typhus, 
all of whom had been exposed to the contagion." 2 Dr. Samuel 
Jackson, formerly of Northumberland, relates several striking in- 
stances, similar to those quoted from Nathan Smith, showing the 
contagious quality of the disease. 3 

The memoir of M. Gendron, upon this subject, is very full and 
elaborate. He adduces a great number of instances, similar to 
those above quoted from Dr. Smith, many of them very striking 
and conclusive, to show the contagiousness of the disease. He 
believes that it is transmissible by direct and repeated contact; 
by the presence of the sick, without contact ; that it may be car- 
ried from a sick person, and communicated to another by a third, 
who does not have the disease ; and, also, that it may be con- 
tracted from exposure to infected clothing, beds, and similar 
fomites. He regards the first-mentioned mode of transmission 
as altogether the most common. The indirect transmission of 
the disease from one individual to another, through the interven- 

1 Smith's Med. and Surg. Memoirs, p. 47. 2 Ibid., pp. 47, 84» 

3 Anier. Jouru. Med. Science., Oct, 1845. 



122 TYPHOID FEVER. 

tion of a third, lie thinks does not often happen, except when it 
is prevailing more or less extensively as an epidemic. The dis- 
ease is most frequently communicated to those who are in the 
closest and most constant relation to the sick — their nurses, and 
immediate attendants. 

According to the observations of M. Gendron, typhoid fever 
propagates itself very slowly by contagion. The interval be- 
tween the successive cases varies from three weeks to a month ; 
so that the fever is often several months in spreading through a 
village, or neighborhood. The period of incubation, he thinks, 
rarely exceeds eight or ten days, though it sometimes extends to 
fifteen, and is occasionally as short as twenty-four hours. He is 
also led to the conclusion that the power of transmission, or com- 
munication, does not exist in the early period of the disease ; that 
it is rarely active before the sixteenth day ; and, in general terms, 
that it continues from the third week to an indefinite period, 
including convalescence. He states some facts which seem to 
show that the contagious matter of the disease may remain ac- 
tive in a bed for two or three years. He supposes it probable 
that certain circumstances connected with the disease in the 
country, such as small, close rooms, and the more constant pre- 
sence of their attendants with the sick, may render its contagious 
character more obvious and certain there than in cities. He 
acknowledges that, in many instances, he has been wholly unable 
to ascertain the source and origin of the first case, from which the 
others have been derived; and he admits, in their fullest extent, 
the great number of examples of immunity from the disease, 
after the most marked exposure ; but he says, very truly, that all 
this is as frequently seen in scarlatina, a disease unquestionably 
contagious, as it is in typhoid fever. 

It is easy to see that this question is one of great practical im- 
portance. It can be fully settled only by further and more vari- 
ous observations ; and these observations, for obvious reasons, can 
be best made amongst the scattered population, and in the small 
villages, of the country. The paper of M. Gendron is drawn up 
with great fairness, and it throws much new and valuable light 
upon the subject, although he sometimes adopts conclusions 
favorable to his opinions which his facts are hardly sufficient to 
justify. He is somewhat too ready, in the present state of our 
knowledge, to consider all cases of the disease, that are in any 



CAUSES. — EXEMPTION FROM SECOND ATTACKS. 123 

way susceptible of being accounted for by the action of a con- 
tagious principle, to be, certainly and necessarily, so accounted 
for. 

Sec. IV. — Exemption from Second Attacks. There is one other 
circumstance bearing upon this question, which it is important 
to notice. I mean the immunity from a second attack which 
seems to be conferred by the occurrence of the disease. M. 
Gendron gives several remarkable instances of this exemption. 
The village of Petit-Genes, containing only fifteen persons, was 
visited by typhoid fever in 1826. Twelve of these persons suf- 
fered from the fever, and of the three who escaped two had had 
it previously. In March, 1829, the disease reappeared in the 
village, apparently introduced by contagion, and was confined to 
a single family, who had taken up their residence here, subse- 
quent to the year 1826. Five members of this family had the 
fever, and although they were constantly visited, and nursed dur- 
ing the nights, by their neighbors, the subjects of the disease in 
1826, the fever did not extend beyond the family. 1 Chomel 
says that, of one hundred and thirty patients, at the lintel Dieu, 
no one, so far as this point could be ascertained, had previously 
had the disease. 

The same immunity was noticed by Nathan Smith. He says : 
"My own personal experience is strongly in favor of the opinion 
I have advanced of the non-liability of the same individual to a 
second attack of typhus ; for during the twenty-five years, since 
I first attended patients in this disease, and in that time I have 
visited many hundreds, and have witnessed its prevalence several 
times in the same village, I have never known nor heard of its 
recurrence in the same person. 

"I once attended a numerous family, every member of which 
was sick of typhus, except two, who escaped at that time ; but 
two years afterward, when the disease again appeared in that 
neighborhood, those two individuals of the family, and those alone, 
were attacked. 

"In another family which I attended, consisting of eight per- 
sons, five of the eight had the disease during the autumn and 



1 Memoir sur les epideruies des petites localites. Par M. Gendron. Journal 
des Connaissances Medico-chirurgicales. Annee, 1834. 



124 TYPHOID FEVER. 

early part of the winter, and recovered. The next summer, the 
remaining three, and another person who had been added to the 
family after the former sickness, were attacked by it, while all 
those previously affected escaped." 1 In 1840, there was an ex- 
tensive local epidemic of typhoid fever in the town of Richmond, 
Berkshire county, Massachusetts. It was carefully observed by 
Dr. Jennings ; some of the cases were seen by Dr. Alonzo Clark, 
one of the most accurate and accomplished diagnosticians in the 
country, so there could have been no doubt as to the true charac- 
ter of the cases. The epidemic reappeared in 1841, and three of 
forty-six persons suffered with a second attack of the fever. There 
were forty-six cases during each year. 2 It need hardly be said 
that this character of typhoid fever, if fully established, although 
not in itself positive evidence, does, nevertheless, constitute a strong 
ground of belief, resting on analogy, for the contagious nature of 
the disease. 

Sec. V. — Epidemic Influences. Typhoid fever occurs both in 
a sporadic and epidemic form. Single, isolated cases are not 
unfrequently met with ; extensive regions of country are some- 
times entirely exempt from the disease, for considerable periods 
of time; and again it often prevails, as I have already had occa- 
sion to say, either in circumscribed neighborhoods, or over wider 
ranges of country, so generally and extensively as to assume an 
epidemic character. The disease, in this epidemic form, as I 
have before stated, becomes migratory in its character, wander- 
ing about the country, attacking one neighborhood this year, an- 
other the next, and so on. It frequently happens that the disease 
returns, at nearly the same season, to the same locality, for two 
or three years in succession, and then wholly disappears. 

Sec. VI. — Age. The influence of age in the production, or 
perhaps in the permission, of typhoid fever is very striking, and 
very accurately ascertained. Setting aside, for the moment, the 
early period of life, this disease generally occurs between the 
fifteenth and thirtieth years. It would seem probable that a 
majority of cases occur during the seven years between eighteen 

1 Smith's Med. and Surg. Memoirs, p. 52. 

2 Dr. Jennings's Letter to Prof. Clark. 



CAUSES. — AGE. 125 

and twenty-five. It is not often seen after the fortieth year, and 
but few cases are recorded in which it has occurred after the 
fiftieth year. Of one hundred and thirty-eight cases, analyzed 
by Louis, fifty-nine were between the ages of twenty and twenty- 
five years. Of one hundred and seventeen cases, mentioned by 
Chomel, ninety-one were between the ages of eighteen and thirty 
years. The average age in two hundred and ninety-one cases, 
occurring in the Massachusetts General Hospital, analyzed by 
Dr. Jackson, was twenty-two years and a third, nearly. In these 
cases, the average age of the females was somewhat more than a 
year greater than the average age of the males. I do not know 
whether this difference has been noticed elsewhere by other ob- 
servers. It may also be stated here, although I shall have occa- 
sion to speak of it more particularly when I come to treat of the 
prognosis in this disease, that the average age of the fatal cases 
is somewhat greater than of those which recover. 

Dr. Jenner says: "Of nearly 400 individuals suffering from 
typhoid fever received into the London Fever Hospital, three only 
have been more than fifty years of age ; the ages of these three 
individuals were respectively 51, 55, and 55 years. Two of them 
were women, one a man. A brief account of the latter case is 
contained in the present paper. The fact that typhoid fever is 
very rarely observed after the age of fifty has been confirmed by 
every observer of the disease." 

I am inclined to think that this disease occurs more frequently 
after the fortieth year of life in the country than seems to be the 
case in cities. Nathan Smith says nothing about its being par- 
ticularly prevalent amongst the young ; and in Gendron's memoir 
upon the disease, as it occurred in one of the French provinces, 
seven cases are mentioned in which the patients were between 
forty and fifty ; three, where they were between fifty and sixty ; 
and four, where they were between sixty and seventy-five years 
of age. I once saw an unequivocal case in a country-woman 
sixty-three years old. M. Lombard, of Geneva, relates a case 
occurring in a woman seventy-three years old. 1 

The opinion which I expressed above, in the first edition of my 
book, finds a striking corroboration in Dr. Jennings's account of 
the epidemic at Richmond, Berkshire county, Massachusetts, in 

1 Rep. Ann. de la Soc. Med. de GeneYe, lS43 r p. 21. 



126 TYPHOID FEVER. 

1840, 1841, and 1842. The whole number of cases, during this 
epidemic, was ninety-eight ; and the average age was thirty-two 
years and two-thirds, although in this number are included, nine 
children, from five to twelve years old. Forty-five, nearly half, 
were thirty-five years old, or over ; forty-one were forty years old, 
or over ; twenty-one were fifty years old, or over ; and eight were 
sixty years old, or over. The oldest was seventy-one. 1 

Amongst the young, typhoid fever occurs most frequently be- 
tween the ages of nine and fourteen years. From five to eight, 
it is less frequent ; and still less so at an earlier period. Of one 
hundred and twenty-one cases reported by Taupin, ten were in 
children not over four years old ; one case occurred at two years ; 
a few, earlier than this ; and one, at seven months. 

Sec. VII. — Sex. The influence of sex in the production of 
typhoid fever is not determined. Nathan Smith did not notice 
any difference in the liability of the two sexes. Dr. James Jack- 
son expresses his belief that the disease occurs amongst men 
much more frequently than amongst women. M. Tardieu ob- 
served that, at the village of Ventenges, in France, in 1835, 
women and children were most frequently attacked. M. Ruef 
says that, in the epidemic of Bischoffsheim, in 1832, females suf- 
fered more extensively than males. These facts may, perhaps, 
be accounted for by the more frequent and constant exposure to 
the sick, to which females are subject in their capacity of nurses 
and attendants. Of ninety-eight cases occurring at Richmond, 
Massachusetts, thirty-eight were amongst males and sixty 
amongst females. Of Barthez and Rilliet's one hundred and 
eleven children with the disease, eighty were boys and thirty- 
one girls ; of Taupin's one hundred and twenty-one cases, eighty- 
six were amongst boys and thirty-five amongst girls. 

Sec. VIII. — Race. Whether the liability to typhoid fever is 
in any degree influenced by race or not, I am unable to say. I 
have often made the inquiry of practitioners in Kentucky as to 
the comparative liability of the two races to the disease, but with- 
out any satisfactory result. Dr. Mattingly, of Bardstown, is 
inclined to think that negroes are somewhat less subject to the 

1 Dr. Jennings's Letter to Professor Clark. 



CAUSES. — OCCUPATION. — RESIDENCE. CROWDING. 127 

disease than whites. Dr. Sutton, of Georgetown, Ky., saw in 
184G forty-three cases ; thirteen of these were amongst negroes. 1 
Dr. Lewis, of Mobile, says: "In the winters of 183.3, 1836, 
and 1837, hundreds of negroes died of a low typhoid fever in the 
middle part of Alabama. All infectious diseases, which prevail 
usually in winter and spring, attack them more violently than 
the whites." 2 

Sec. IX. — Occupation. There is no evidence that any occu- 
pation or profession in itself in any way predisposes to this dis- 
ease, or preserves from it. 

Sec. X. — Recency of Residence. The researches of Louis and 
Chomel show, conclusively, that, in the city of Paris, typhoid 
fever occurs more frequently amongst new than amongst old 
residents. This difference is very great. Of Louis's one hun- 
dred and twenty-nine patients, all but twenty-seven had resided in 
Paris only twenty months, or less ; forty-four only five months, 
or less ; and only four had resided there from infancy. Of Cho- 
mel's ninety-two patients, at the Hotel Dieu, forty-five, almost 
one-half, had resided in Paris only one year, or less ; and only 
two had lived there from infancy. I do not know whether this 
influence has been noticed in our own cities. In the city of 
Lowell, the disease has generally attacked those who have not been 
long residents there ; but it would not be safe to rely upon this 
fact alone, since a large part of the young population of that 
place have been residents, at most, for only a few years. It is 
very certain, I think, that the influence now under consideration 
cannot be so obvious in the country as in large towns and cities. 
No notice is taken of it by that sagacious and careful observer, 
the late Nathan Smith. I have known the disease to prevail 
extensively, and in a very grave form, amongst the permanent 
residents of a country village. This, indeed, is a frequent occur- 
rence in the agricultural regions of our Eastern States, and of 
France, where the population is generally native and fixed. 

Sec. XL — Filth, Crowding, £c. In regard to the action of 
putrid substances, and to the influence of scanty and unhealthy 

» Letters to author. 2 N. 0. Med. Journ., vol. i. p. 417. 



128 TYPHOID FEVER. 

food, it is sufficient, perhaps, to say, that there is no satisfactory 
evidence of their operation in giving rise to the disease. 

Piorry is of the opinion that a majority of the patients in the 
Paris hospitals are received from small and poorly ventilated 
lodgings; but the influence of this cause in giving rise to typhoid 
fever is not generally admitted, and certainly does not seem to be 
very evident. 1 

Sec. XII. — Exposure; Excesses, $e. The effect of what are 
usually regarded as the most common exciting causes of many 
forms of disease, such as exposure to cold, strong moral impres- 
sions, errors of diet, and excesses, is not very obvious, in the pro- 
duction of typhoid fever. Of one hundred and fifteen patients, 
at the H6tel Dieu, who were examined by Chomel upon this 
point, seventy-nine were wholly unable to refer the access of the 
disease to any appreciable cause. It may be added, further, that 
persons suffering from the disease are generally, immediately 
previous to the attack, in full health. 

1 Clinique Medicale de l'Hopital Pitie. Par P. A. Piorry, p. 175, et seq. 



129 



CHAPTER V. 

VARIETIES AND FORMS. 

Typhoid fever, like almost all diseases, exhibits many varieties 
in its character and appearances, some of which, before proceed- 
ing to speak of its diagnosis, it is important to notice. One of 
these varieties depends upon the degree of severity of the disease. 
Louis divides his cases into three classes; consisting, first, of 
those which terminated fatally; second, of those which were 
grave and severe, but which recovered; and, third, of those 
which were mild. It is obvious enough that this arrangement is 
somewhat arbitrary ; that the several degrees of severity must run 
off, by imperceptible gradations, like the colors of the spectrum, 
into each other ; and that, oftentimes, the line of demarcation 
between the classes must be shadowy and doubtful. Neverthe- 
less, the distinction really exists ; in a great majority of cases, 
there is but little difficulty in recognizing and appreciating it ; 
and it is one, not only of convenience, but of great practical 
value and importance. 

It is a very common occurrence for nearly all the more grave 
and alarming symptoms of the disease to be absent from its com- 
mencement to its termination in health ; and where its diagnosis 
is not well understood, these cases are often mistaken for some 
other disease. Under these circumstances, there is, frequently, 
but slight febrile excitement ; little or no thirst ; no affection of 
the mind; no diarrhoea; no pains in the abdomen. The patient 
sleeps well, the tongue may be nearly clear, slightly sticky, or 
covered only with a thin, brownish coat ; there is little or no rest- 
lessness, or suffering of any sort, and the patient wonders why he 
is sick, and why he is obliged to lie in bed. But he is obliged to 
lie in bed. Place him in his chair, and he very soon wishes to 
get back to his bed. On assuming a sitting or upright position, 
he finds that he does not feel so well; his muscular strength is 
gone ; his debility, though not extreme, is out of proportion to 
9 



130 TYPHOID FEVER. 

his other symptoms ; and he is troubled, perhaps, with dizziness, 
or ringing in the ears. It will be found on inquiry that either 
suddenly, in the midst of good health, or after a few days of 
vague and indefinite not being well, the patient was attacked with 
a chill, accompanied or immediately followed by pains, generally 
of moderate severity, in the head, back, and limbs. None of 
these symptoms are accounted for by any local disease. In the 
progress of the fever, the headache goes off; there may be some 
degree of deafness ; slight somnolence ; occasional epistaxis ; and, 
during the second week, the lenticular, rose-colored eruption will 
probably show itself upon the abdomen and the chest. In this 
class of cases, after the condition thus described has continued 
with but little change during a period of from two to three weeks, 
the strength and appetite begin to return, convalescence is rapid, 
and the patient is soon restored to sound health. 

Between this, the mildest form of the disease, and those of the 
gravest and most dangerous character, there are, of course, all 
possible gradations. It is not necessary to describe them par- 
ticularly. They are marked, in different degrees, by greater 
prostration of strength ; somnolence, followed by or alternating 
with delirium ; twitching of the tendons ; picking at the bed- 
clothes, or at imaginary objects ; a dry, cracked, trembling 
tongue, red, brown, or black ; tympanitic distension of the abdo- 
men, and diarrhoea. 

Dr. Jackson speaks particularly of the predominance of cer- 
tain symptoms during certain periods of time. In 1828 and 
1829, for instance, he had eleven successive cases, in nine of 
which there was dry tongue ; in 1831, this symptom was present 
in eleven of fifteen successive cases ; in 1834, in ten of twelve 
successive cases ; and in 1835, in twenty-two of twenty-seven suc- 
cessive cases. At one period, epistaxis was very common ; at 
another watchfulness, and so on. 1 

There is another phasis, under which the mild form of typhoid 
fever sometimes presents itself, to which Louis applies the term 
latent. The disease in this form cannot be called absolutely 
latent, though it is nearly so. The local lesion of the intestine 
is present ; in some cases, it is positively ascertained to have 
been extensive and profound ; but the disturbance and perturba- 

1 Report, &c, p. 136. 



VARIETIES. — LATENT FORM. 131 

tion of many of the functions of the economy, usually accompa- 
nying this lesion, and constituting the rational symptoms of the 
disease, do not take place, or rather they are very obscure. The 
reason of all this is entirely unknown, and the most we can say 
about it is that the same thing occasionally happens in other 
diseases. The latent form of typhoid fever, like the ordinary 
forms, is commonly marked at its commencement by chills, head- 
ache, and moderate febrile excitement. But the patient is often 
able to sit up, or even to keep about, and there are no prominent 
symptoms of disturbance in the nervous system, or the abdomen. 
It is very curious, as has already been observed, that the cases of 
perforation of the intestine have generally been found to occur 
in this variety of the disease. 

All these different degrees in the severity of typhoid fever are 
frequently witnessed at the same time, during its prevalence in a 
given place. But it often happens with typhoid fever, as it does 
with many other diseases — with the bilious remittent, with true 
typhus, with scarlatina, with pneumonia, and so on — that during 
one season, and in one locality, its prevailing character is mild, 
and its mortality small ; while in another season, its character 
is grave, and its mortality large. Dr. Power, of Baltimore, in- 
forms me in a private letter, dated September 4, 1847, that 
typhoid fever has been epidemic in that city for the last fourteen 
months, and that it has exhibited more of the adynamic character 
than usual, and requiring a more stimulating treatment. I have, 
more than once, seen the disease pretty extensively prevalent, 
when nearly all the cases belonged to the mildest form. In the 
epidemic of the city of Lowell, during the winter and spring of 
1834-5, the cases were generally grave, and the mortality con- 
sequently great. This difference in the severity of the disease 
during different years is very strikingly shown in the records of 
the Massachusetts General Hospital. During fourteen years, 
from 1822 to 1835, inclusive, there were three hundred and three 
cases of typhoid fever, and forty-two deaths ; or one in a little 
more than seven. In the year 1830, the deaths were one in three 
and a half ; in 1831, they were one in fourteen and a half; and 
in 1829, one in twenty-five. From 1832 to 1835, inclusive, the 
number of cases was one hundred and twenty-nine, and the 
number of deaths twenty-two, making a mortality of one in a 
little less than six ; while from 1836 to 1838, inclusive, the num- 



132 TYPHOID FEVER. 

ber of cases was one hundred and eight, and the number of 
deaths seven, making a mortality of one in fifteen. It is still 
more remarkable that, from November, 1836, to November, 1838, 
there were fifty-five successive cases, without a single death! It 
may be added here, that these wide differences in the mortality 
and severity of the disease, in different years, are not to be ac- 
counted for by any differences in the treatment. 1 

Chomel admits several forms or varieties of typhoid fever, not 
depending upon degrees of severity. These are the inflammatory, 
the bilious, the mucous, the ataxic, and the adynamic. They 
depend upon the relative severity, or predominance, of certain 
symptoms, or groups of symptoms. In the inflammatory form, 
there are unusual strength and fulness of pulse ; great heat and 
moisture of the skin, Urgent thirst, and diminished secretion of 
urine. These symptoms are especially prominent only in the 
early period of the disease. According to Chomel, they occur 
oftenest in the robust, and during the winter months. The bilious 
variety is characterized by some yellowness about the lips and 
nose ; a thick, yellowish, or greenish coat on the tongue ; a bitter 
taste ; nausea, and bilious vomiting. Chomel regards this form 
of typhoid fever — which occurs oftenest, he thinks, during the 
summer and autumn, and in particular localities — as identical 
with the bilious fever of authors. There is no doubt, whatever, 
that, in the confusion worse confounded which has always pre- 
vailed throughout the medical world in relation to the diagnosis 
of fevers, and which is even now but very partially dissipated, 
typhoid fever has often been described under the name of bilious 
fever; but it is also quite certain that, if Chomel supposes 
typhoid fever and bilious remittent fever to be identical diseases, 
he is widely mistaken. It is easy to see that there may be a 
bilious variety of typhoid fever, just as there is a bilious form of 
pneumonia. The mucous variety of typhoid fever is not very 
distinctly characterized, even in Chomel's description of it. It 
can hardly be said to exist as a distinct variety. The term 
ataxic is applied to those cases in which there are great severity 
and predominance of the nervous symptoms, such as dulness, 
stupor, perversions of the senses, delirium, and spasms ; or to 

1 Hale on the Typhoid Fever of New England. Communications of the Mass. 
Med. Soc., vol. vi. part iii. pp. 254, 255. 



VARIETIES AND FORMS. 133 

those in which the disease is masked, and rendered irregular, by 
a want of the usual correspondence in degree of severity between 
the more important symptoms. In these cases there may be 
little or no delirium, or the pulse may be almost natural when 
the disease is manifestly hurrying on to a fatal termination. The 
adynamic form is marked by extreme debility, and prostration 
of strength, present at the commencement, or coming on in the 
course of the disease. The mind is lethargic ; the pulse is feeble 
and soft ; the urine and the cutaneous transpiration are fetid ; 
and the disease is often prolonged beyond the fourth week. 1 

1 Chomel's Le9ons de Clinique Medicale, p. 340, et seq. 



134 



CHAPTER VI. 

DURATION, MARCH, AND COMPLICATIONS. 

ARTICLE I. 

DURATION. 

It is not often an easy matter to determine, with accuracy, the 
duration of a disease. Both extremities of the space to be mea- 
sured are indistinctly defined. This is especially true of typhoid 
fever. The access of the disease is often gradual, and convales- 
cence establishes itself by slow and almost imperceptible degrees. 
There is often, also, here another source of difficulty, arising from 
the state of mind in which the patient is found. His impressions 
are cloudy, his recollections are indistinct, and he will often date 
the commencement of his illness several days later than it really 
occurred. Dr. Jenner says the patient always believes that a 
longer time has elapsed since the commencement of his disease, 
or since the occurrence of any given event, than has really passed 
away. 

Bearing these circumstances in mind, I proceed to state, as 
nearly as has been ascertained, the usual duration of the disease. 

Dr. Jackson, following the example of Louis in regard to pneu- 
monia, fixes the commencement of convalescence at the time 
when the patient is able to take a moderate quantity of solid food, 
the febrile symptoms having subsided for at least two or three 
days previous to this period. In two hundred and fifty-five cases, 
at the Massachusetts General Hospital, between the years 1824 
and 1835, inclusive, the average duration of the disease was 
twenty -two days. It was a little less than this in those under 
twenty-one years old, and a little more in those over. The dura- 
tion varied in different years, from eighteen to twenty-six days. 
Dr. Jackson thinks that convalescence commences, in a few rare 



MARCH AND COMPLICATIONS. 135 

instances, as early as the seventh day. 1 Of one hundred and 
eighty-six cases, at the same hospital, between October 1, 1833, 
and October 1, 1839, the average duration was thirty-nine days. 2 
Of sixty-eight cases terminating favorably, cited by Chomel, he 
says that there was a decided change for the better, in fifty, be- 
tween the fifteenth and thirtieth days ; and in more than one-half 
of these, it took place between the twentieth and twenty-fifth. 3 
Nathan Smith says that he has rarely seen the disease terminate 
under the fourteenth day from its commencement; and that it 
rarely extends beyond the sixtieth. 4 Of the forty-six fatal cases, 
analyzed in the great work of Louis, ten terminated between the 
eighth and fifteenth day; seven, between the sixteenth and twen- 
tieth ; twenty, between the twentieth and thirtieth ; and nine, after 
this period. 5 Of forty-six cases occurring in Richmond, Berkshire 
County, Massachusetts, between August, 1840, and February, 
1841, the average duration was nearly forty-one days. It ought 
to be stated, however, that the duration in three of these cases is 
stated, respectively, at one hundred, one hundred and seventy- 
three, and two hundred days. This extreme prolongation was 
probably caused by some accidental complication. Forty-six 
cases occurred in the same town, between August, 1841, and 
May, 1842; the average duration in these being a little more than 
thirty-three days. No death took place earlier than the twelfth 
or thirteenth day; in no case of recovery, was the duration less 
than sixteen days. 6 

ARTICLE II. 

MARCH AND COMPLICATIONS. 

The march of the disease is, on the whole, pretty uniform and 
regular. In cases of average severity, the patients get gradually 
sicker, from day to day, for two or three weeks ; or, after the first 
week, their condition may continue, with very little change, until 

r Dr. Jackson's Report on Typhoid Fever, pp. 108, 109, 110, 111. 

2 Hale on the Typhoid Fever of New England, p. 211. 

3 Chomel' s Lemons de Clinique Medicale, p. 44. 
* Smith's Med. and Surg. Memoirs, p. 56. 

6 Lonis on Typhoid Fever, vol. i. p. 134, 2d ed. 
6 Dr. Jennings's Letter to Dr. Clark. 



136 TYPHOID FEVER. 

convalescence commences. The disease is not usually marked 
by great and sudden alterations, either favorable or unfavorable, 
though these do sometimes occur. Neither is it marked by 
distinct stages, although Chomel divides it into three septenary 
periods, dating from the distinct and formal onset of the disease. 
This is arbitrary, but very well as a matter of convenience. ' 

Typhoid fever is occasionally, but not often, complicated with 
other diseases. Nathan Smith says that he has often seen it fol- 
low dysentery, and that he has known it to coexist with epidemic 
catarrh. Chomel gives a case in which it was complicated, at 
its commencement, with acute pneumonia. Erysipelas sometimes 
occurs in the course of the disease, and this more frequently dur- 
ing some seasons than others. During the winter of 1846-7, 
in Lexington, Kentucky, there were several cases attended with 
a bright erysipelatous redness of the nose ; and the same redness 
was seen in some persons not suffering with the fever. 

ARTICLE III. 

PERITONITIS. 

There is one other accident liable to occur in the progress of 
typhoid fever, of which it is necessary to speak more particularly ; 
I mean acute inflammation of the peritoneum, occasioned by the 
discharge into its cavity of the contents of the small intestine, 
through a perforation. The lesion itself has already been de- 
scribed. It was first fully investigated, its nature and causes 
pointed out, and its diagnosis established, by Louis. 2 In a ma- 
jority of instances, it takes place in cases of moderate severity, or 
in those which have been described as latent, and at a late period 
of the disease. Its occurrence is marked by the sudden super- 
vention of acute pain in the abdomen. This pain comes on, all 
at once, with no premonitory symptoms, with nothing in the con- 
dition of the patient to account for it, and the suffering which it 
occasions is excessive. The access of the pain is frequently ac- 
companied by chills, the abdomen becomes rapidly and acutely 
tender on pressure, and, if it was not so before, hard and tym- 

1 Le^ns de Clinique M^dicale. Chomel, p. 6. 

2 Memoires sur diverses Maladies, Paris, 1826, p. 156, et seq. 



RELAPSES. 137 

panitic. The pulse is quick and compressed. An instantaneous 
change takes place in the physiognomy of the patient. The 
countenance is expressive of intense suffering ; the features are 
pinched and cadaverous ; and the face is covered with a profuse 
sweat. There is a constant and urgent desire for cold drinks. 
Nausea and vomiting are present soon after the inflammation has 
commenced ; the matter ejected from the stomach is of a grass 
green color, and it continues to be thrown up to the last moment 
of life. Notwithstanding the constancy and the intensity of the 
distress, the patient preserves the same position, lying upon his 
back, and dreading every movement that may add to the pain and 
tenderness of the abdomen. Such, in most cases, is the formi- 
dable array of symptoms which indicate the occurrence and mark 
the progress of this fatal complication. Occasionally they are 
more obscure ; and this peritoneal inflammation, like the fever 
itself, is to a certain extent latent. It is exceedingly rare, how- 
ever, that there can be any difficulty in ascertaining its existence. 
Death usually takes place in from one to three days after the 
occurrence of the perforation. 

ARTICLE IY. 

RELAPSES. 

It seems to be very well settled that true relapses, as they are 
called, not unfrequently occur in this disease. Dr. Jackson re- 
marks that an error in diet and regimen is often followed by a 
new train of symptoms, after convalescence from typhoid fever ; 
and that they appear to be such symptoms as belong to the fever, 
although not always so strongly characteristic as to leave no 
doubt on the subject. He cites a case in which, during the re- 
lapse, there was an eruption of the rose spots. Dr. Stewart re- 
ports two cases wherein, amongst many other of the more peculiar 
symptoms of the disease, the relapses were also attended by a re- 
appearance of the typhoid eruption. 1 Indeed, there are probably 
few physicians extensively conversant with typhoid fever, who 
have not, more than once, seen convalescence fatally interrupted 
by a sudden return or an aggravation of many of the most cha- 

1 Edin. Med. and Surg. Journ., Oct. 1840. 



138 TYPHOID FEVER. 

racteristic symptoms of the disease, the delirium, the diarrhoea, 
the subsultus, the tympanites, and so on ; constituting, not the 
supervention of a new accidental affection, but a genuine relapse. 



ARTICLE V. 

SEQUELS. 

The most serious sequel of typhoid fever is tubercular con- 
sumption. This has been particularly noticed by Dr. Gerhard, 
of Philadelphia. In patients of a strumous or cachectic habit, 
it not unfrequently follows immediately, or very soon, upon the 
fever, and usually runs on with great rapidity to a fatal termina- 
tion. 

Dr. Jackson notices a painful state of one or both legs, coming 
on after convalescence, attended with more or less lameness in 
motion, causing much anxiety, and continuing from a few days 
to several weeks. There were eight cases of this kind in the 
hospital. Entire recovery took place in all. Dr. Jackson also 
mentions five cases in which, at a late period of the disease, 
there was swelling of one leg from well marked phlebitis. 1 
Nathan Smith alludes to the same occurrence. 2 I have seen this 
swelled leg in only one instance. Barthez and Rilliet have met 
with several cases of anasarca during convalescence. 

1 Dr. Jackson's Report on Typhoid Fever, p. 133. 

2 Smith's Med. and Surg. Memoirs, p. 67. 



139 



CHAPTER VII. 

MORTALITY AND PROGNOSIS. 

Typhoid fever must be considered, on the whole, as a grave 
disease. I have already had occasion, in treating of its different 
forms and varieties, to give some instances of its rate of mortality 
in different seasons and places. 1 This depends so much upon 
the character of the disease, in any particular locality, and during 
any given period, that it is not an easy matter to arrive at any 
positive and accurate general or average result. The prognosis, 
as well as the diagnosis, of this disease, is a complex problem, 
into the solution of which, in each individual case, there enter a 
great number of phenomena. Instead of going any further into 
the question of the average and varying mortality of the disease, 
I will now endeavor to appreciate, as far as this can be done, the 
value of the several elements which go to make up our prognosis. 
In doing this, I shall first briefly pass in review, and, as nearly 
as this can be done, in the same order in which they have already 
been described, the several symptoms of the disease; and I will 
then speak of some other considerations, connected with its degree 
of severity, and consequent danger. 

The mode of invasion would seem to have no small degree of 
influence upon the subsequent character of the disease. This has 
been particularly shown by the investigations of Chomel. In 
his wards at the Hotel Dieu, of seventy-three cases in which the 
access was sudden only twenty-six were fatal ; while there were 
twenty deaths in only thirty-nine cases in which the access was 
gradual. 

The strictly febrile symptoms are not, in themselves, of much 
value in prognosis. A pulse more rapid than 120 or 180 in the 
minute constitutes an unfavorable sign ; especially if associated 
with any other grave symptoms. Still, it frequently happens, 

1 See pages 131, 132. 



140 TYPHOID FEVER. 

that cases recover in which this rapidity of the pulse has been 
present for a considerable period of time. In two hundred and 
ninety cases, cited by Dr. Jackson in his Report, the average 
frequency of the pulse in those which recovered was, in round 
numbers, about twenty in a minute less than in those which ended 
fatally. It was also from fifteen to twenty in the minute more 
frequent in females than in males. Dr. Jackson remarks,' in his 
Report, that he has not found chills, at an advanced or late period 
of the disease, to have been followed by very grave consequences, 
though he had previously had a different impression. Of twenty- 
nine cases in which these chills were noted, only two terminated 
fatally. Louis says that they indicate the commencement of 
some secondary lesion. 

The noisy, hissing, and irregular respiration, to which I have 
applied the term cerebral, is a very dangerous indication ; and, 
as is said by Chomel, when connected with other grave symptoms, 
renders the case almost utterly hopeless. 

Delirium, especially if it occurs at an early period, and is of a 
wild and violent kind, is of very bad augury. Many patients, in 
whom it comes on late, and in whom it is of a mild, muttering 
character, recover. Of one hundred and eight cases, mentioned 
in Dr. Jackson's Report, this symptom was present in two cases 
in seven of those which terminated favorably ; and in four cases 
in five of those which terminated unfavorably. Transient and 
slight delirium, occurring during the night, or immediately after 
waking from sleep, and easily dissipated by attracting the atten- 
tion of the patient, cannot, in itself, be regarded as a very serious 
symptom. There is a peculiar perversion of the mind, occasion- 
ally seen, the presence of which indicates great and imminent 
danger. This consists in a feeling, on the part of the patient, 
that he is not much sick ; when he says, even in the midst of the 
gravest symptoms, that he feels, and that he is, very well. Louis 
says that he has never known this state of the mind in a patient 
who recovered. 

Somnolence and coma are unfavorable symptoms, in proportion 
to their degree, and to the early period of their access. If they 
are present at or near the beginning of the disease, and are at all 
strongly marked, they are very constantly followed by a fatal ter- 
mination. Moderate sleepiness or stupor, from which the patient 
is pretty readily roused, is common in cases of moderate severity ; 



MORTALITY AND PROGNOSIS. 141 

but prolonged and profound coma indicates a very formidable 
grade of the disease. Watchfulness, restlessness, and agitation 
are also unfavorable symptoms. Deafness and epistaxis are, 
neither of them, of any considerable importance as prognostic 
signs. They occur with nearly the same frequency, and to near- 
ly the same extent, in grave and in mild cases. The same thing 
is true of dizziness, and noises in the ears. 

Spasmodic contractions of the muscles, either of the face, or of 
the arms and hands, constituting subsultus tendinum, or of other 
parts of the body, are of grave omen. They occur very much 
more frequently in cases which are fatal than in those which re- 
cover. According to Dr. Jackson's Report, they were noted, at the 
Massachusetts General Hospital, in one case in a little less than 
four of those which terminated unfavorably ; and in one case in 
ten of those which terminated favorably. If these contractions 
are general and strongly marked, constituting a kind of epilepti- 
form agitation of the whole body, or of all the limbs, the case is 
almost invariably fatal. Such is also the case where there is 
permanent rigidity of one of the limbs. Louis has never seen a 
case of this sort recover ; and he says that he knows of no one 
amongst his contemporaries, except Chomel, who has. Barthez 
and Rilliet saw five cases of rigidity of the muscles of the trunk, 
in children, all of which terminated fatally ; and two cases of 
convulsions, which ended also in death. Dr. Jackson reports six 
cases, in which this symptom occurred, only one of which ended 
in recovery. Early and extreme prostration of strength is likely 
to be followed by a grave and dangerous form of the disease. 

The expression of the countenance may sometimes be of ser- 
vice in our prognosis. It is hardly necessary to say that the 
pinched, cadaverous, Hippocratic face generally indicates speedi- 
ly approaching dissolution. On the other hand, the reappear- 
ance of intelligent expression on the features, from which it had 
long been banished ; the re-illumination of the dull and listless 
eye ; the recognition by the patient of his friends and attendants ; 
accompanied by the manifestation of interest in his own situa- 
tion and safety, and in surrounding circumstances, are, even in 
the midst of many grave symptoms, cheering indications of a 
change that will end in recovery. 

The appearance of the tongue is of less importance as a prog- 
nostic sign than has generally been supposed. It is worth some- 



142 TYPHOID FEVER. 

thing, but in itself not a great deal. In Dr. Jackson's eases, 
the rate of mortality, with a dry tongue, was 1 in 47.1 ; with a 
denuded tongue, 1 in 8 ; with a dark tongue, 1 in 3.23. 1 A very 
dry, cracked, red or blackish tongue is more unfavorable, cer- 
tainly, than one that is moist, with a thin, brownish, or yellowish 
coat ; but the former appearances are not unfrequently present in 
cases which recover, and, unless accompanied with other grave 
symptoms, are not much to be regarded. 

Difficulty of swallowing, especially if great, is an unfavorable 
sign. 

Meteorism, or tympanitic distension of the abdomen, constitutes 
an unfavorable symptom only when it is strongly marked. 2 

Diarrhoea, if urgent and continued, is a grave symptom. It is 
much more constantly present in severe and fatal cases than in 
mild ones, although patients often recover who have suffered 
greatly and for a long time with it. Nathan Smith says : " The 
danger of the disease is in proportion to the violence of the diar- 
rhoea; when the patient has not more than four or five liquid 
stools in the twenty-four hours, it is not alarming, as it does not 
seem to weaken him much ; but if they exceed that number, serious 
consequences may be apprehended. I have never lost a patient 
whose bowels continued constipated through the whole course of 
the disease, and have never known a fatal case of typhus, unat- 
tended by diarrhoea." 

Involuntary discharges from the bowels rarely take place, ex- 
cept in the late stage of very severe cases. Of course, they point 
towards an unfavorable termination, although they are far from 
indicating with any certainty such a result. Of thirty cases in 
which this symptom was present, mentioned by Chomel, thirteen 
ended in death. Of ten cases, cited by Dr. Jackson, only four 
recovered. 

Hemorrhage from the bowels is a grave symptom, though far 
from an invariably fatal one. Of seven cases, cited by Chomel, 
all but one terminated unfavorably. The experience of others, 
however, is less discouraging. Of seven cases, mentioned by 
Louis, three were fatal ; and of thirty-one cases, occurring in the 
Massachusetts General Hospital, eleven only terminated unfavor- 
ably. I have certainly seen as many instances of recovery, as of 

1 Report, &c, p. 115. 2 Louis on Typhoid Fever, vol. ii. p. 841, 2d ed. 



MORTALITY AND PROGNOSIS. 143 

death, in patients who have suffered from this accident. I do not 
know that the quality of the intestinal discharges, in any other 
respect, has any constant relation to the danger of the disease. 

Retention of urine is an unfavorable symptom. Of six cases 
in which it was present at the Massachusetts General Hospital, 
three were fatal. 

Erysipelas occurs oftenest in the course of severe and alarming 
cases. It not only indicates a grave form of the disease, but it 
adds also to its danger. The rose spots occur with like frequency 
in all grades of the disease, and are destitute, of course, of any 
prognostic value. The same remarks may be made of eschars 
upon the sacrum, as have just been made in regard to erysipelas. 

Before leaving this consideration of the several symptoms of 
typhoid fever, in their relation to prognosis, it is important to 
notice one other circumstance, of occasional occurrence, bearing 
upon this subject. It sometimes happens that a very well marked 
amelioration of all the symptoms takes place somewhere, usually, 
between the tenth and twentieth days of the disease ; constituting, 
indeed, an apparent convalescence ; and that this amendment is 
soon after followed by the return, in an aggravated form, of the 
symptoms which had subsided or diminished, in severity. This 
species of relapse is almost invariably followed by death. This 
circumstance is particularly noticed by Chomel, and the truth of 
his remarks is corroborated by Louis. 

Besides the foregoing, there are some other circumstances 
which affect in a general way the question of prognosis in typhoid 
fever. The principal of these are age, season, and acclimation. 

Speaking now of adult patients, that is of those over fifteen 
years old, it seems very certain that the danger to be apprehended 
from this disease is somewhat in proportion to their increased 
age. The mortality is smaller between the ages of fifteen and 
twenty than it is between the ages of twenty and twenty-five ; or 
than it is at any subsequent period of like duration. The mor- 
tality at the Hotel Dieu, in Chomel's wards, was one in five, 
between the ages of fifteen and twenty ; one in four, between the 
ages of twenty and twenty-five ; and one in two, over the age of 
thirty-five. Louis and Chomel agree in saying that they have 
rarely found cases to terminate fatally, where the patients were 
between the ages of fifteen and seventeen years. At the Massa- 
chusetts General Hospital, Dr. Jackson found the average age in 



144 TYPHOID FEVER. 

the fatal cases to be a little more than two years greater than 
in the cases not fatal. He found also, upon a further analysis, 
that in those patients whose ages were thirty-five years or more, 
the mortality was one in four ; while in those whose ages were 
twenty years or less, it was only one in nearly eleven. The prog- 
nosis is said to be more favorable amongst children than amongst 
adults ; but of Barthez and Rilliet's one hundred and eleven cases, 
twenty-nine terminated fatally. 

It would appear, from the observations of Chomel, that typhoid 
fever is more grave and fatal in the cold, than it is in the warm 
season. At the H6tel Dieu, in 1832, the mortality was one in 
three during the winter, and one in six during the summer ; in 
1834, it was one in two and a half during the winter, and one 
in seven during the summer ; and in 1835, the average "propor- 
tions were the same as in 1832. An exception to this general 
result occurred in 1831, when the proportion of deaths was one 
in four during the winter, and one in three during the summer. 
The number of cases, however, in the hospital, this year, was 
small. Chomel appears to have no doubt as to the influence of 
season upon the severity and mortality of the disease. 1 I do not 
know how far his conclusions are sustained by the observations of 
others. The most fatal form of the disease that has ever been 
witnessed in the city of Lowell prevailed during a winter of 
extreme severity. In the Massachusetts General Hospital, from 
1822 to 1835, the rate of mortality during the cold months was 
1 in 6.39; while in the warm months it was only 1 in 8.21. 2 

Of one hundred and eighty-three cases given by Forget, forty- 
three terminated fatally. The rate of mortality varied with the 
seasons in the following manner : in the autumn, it was one in 
4-^3 ; in the winter, one in 3 T \; in the spring, one in 3 T 5 r ; and 
in the summer, one in 6J. 3 

It seems, also, and this principally from the results obtained 
by Chomel, at the H6tel Dieu, that the length of time during 
which patients have resided wherever they suffer from the dis- 
ease, has some influence upon its mortality. Between the 1st 
of November, 1834, and the 1st of August, 1835, there were 
ninety cases of typhoid fever in Chomel' s wards at the H6tel 

1 La Lancette Fran9aise. August, 1835. 

2 Dr. Jackson's Report, p. 107. 

3 Traite de l'Enterite Folliculeuse. Par C. P. Forget, p. 409. 



MORTALITY AND PROGNOSIS. 145 

Dieu. Amongst those patients who had resided in Paris less 
than one year, the mortality was one in three ; amongst those 
who had resided in Paris between one and two years, the mor- 
tality was one in five ; and of fifteen, who had resided in Paris 
more than two years, only one died. There is reason to think 
that this result is not accidental, since the same differences, 
though to a less striking extent, were noticed during the three 
previous years, and since they are also in keeping with the obser- 
vations of Louis. 1 Chomel has suggested that a certain degree 
of general debility, either constitutional or the result of previous 
disease, may act favorably upon the severity and the termination 
of typhoid fever. Forget says he has often been struck with the 
rapidity with which the disease has run on to a fatal termination 
in cases of young persons with rich, vigorous, and fine constitu- 
tions, so that it was not without a secret terror that he saw these 
patients enter the hospital. 2 

Whether typhoid fever is any way influenced in its severity by 
race, I am unable to say. During the year 1846, Dr. Sutton, of 
Georgetown, Ky., saw forty-three cases of the disease. Thirty 
of these were amongst whites, and eight of them were fatal — 
1 in 4 ; thirteen were amongst negroes, two of which were fatal 
— 1 in 6J. These numbers are of course too small to be in 
themselves of much value. 

There is no evidence that the supposed occasional exciting 
causes of typhoid fever, such as scanty and poor diet, depressing 
emotions, fatigue, and excesses, have any effect upon the severity 
and fatality of the disease. 

It must be obvious enough, from all the foregoing considera- 
tions, that the prognosis, in any given individual case of typhoid 
fever, can very rarely, if ever, be absolute and positive. Patients 
sometimes recover from the most desperate condition ; they are 
liable to the most dangerous and fatal accidents, in the mildest 
cases. But, notwithstanding these contingencies, we may, in a 
great majority of instances, by a careful study of all the circum- 
stances which can influence the result, arrive at a good degree of 
approximative certainty in our prognosis. In a moderate pro- 
portion of cases, the scales of life and death may hang for many 

1 La Lancette Fra^aise. August, 1835. 

2 Traite de l'Enterite Folliculeuse, p. 404. 

10 



146 TYPHOID FEVER. 

days, so far as we are able to see, in almost exact equilibrium; 
and no foresight or sagacity can predict, with any degree of con- 
fidence, which of the two will finally preponderate. Favorable 
and unfavorable symptoms will be so combined, and so attem- 
pered, as to baffle all the efforts of wisdom and experience to 
calculate their issues. Hope and Fear are constant and equal 
watchers by the bedside of the sick. In all the rest, however, 
the general character of the symptoms will be, one way or the 
other, so marked and so decided, as to enable us to judge with a 
reasonable degree of certainty as to the result. If during the 
first fortnight, the pulse is not more than one hundred or one 
hundred and ten in the minute ; if there is only moderate drowsi- 
ness ; if there is no delirium, or even if this, though present, has 
not appeared at an early period of the disease, and is easily dis- 
sipated, or mild in its character ; if there is no twitching of the 
tendons ; if the patient gets some comfortable sleep ; if the diar- 
rhoea and tympanitic state of the abdomen are moderate in 
degree ; the chances of recovery are vastly in favor of the pa- 
tient. Bearing in mind the liability which always exists to a 
sudden aggravation of the symptoms, to the supervention of some 
secondary complication, and to the occurrence of intestinal per- 
foration, and the qualification necessarily accompanying this 
liability, we may in such cases, with great confidence, anticipate 
a favorable result. On the other hand, if the pulse is more than 
one hundred and ten or one hundred and twenty in the minute ; 
if there is great stupor or coma ; if the delirium comes on early, 
and is wild and furious ; if there are spasmodic contractions of 
the muscles, picking at the bedclothes, and great prostration of 
strength ; if there is restlessness or agitation ; if the diarrhoea 
is urgent and continued; if the distension of the abdomen is 
extreme ; if the odor from the patient is musty and cadaverous ; 
if the features are pinched and Hippocratic; especially if there 
are general epileptiform convulsions or permanent rigidity of one 
of the limbs ; or that peculiar perversion of the intellect which 
leads the patient, in the midst of this terrible combination of 
threatening circumstances, to suppose and to declare himself free 
from suffering and danger ; if these symptoms or any consider- 
able number of them, are present, we can have very little ground 
to look for any but a fatal termination ; and this termination we 
may with great confidence predict. 



147 



CHAPTER VIII. 

DIAGNOSIS. 

It is only since the publication of the work of Louis, by the aid 
of his and of subsequent researches, that typhoid fever has been 
distinguished, with any considerable degree of constancy and 
certainty, from other more or less analogous forms of disease. 
And even now, there are few problems in diagnosis more com- 
plex than this; although, by the application of the requisite 
knowledge and care, its solution is almost always attainable. 
The elements which enter into the composition of this problem 
are many and various. There is no one symptom, there are no 
two or three symptoms, which, in themselves, are characteristic 
of the disease. There is no one symptom, there are no two or 
three symptoms, usually occurring in the disease, which may not 
be absent during its entire progress. Our diagnosis can never 
be founded here, as it is in many other instances, on a few posi- 
tive physical signs. It must always be rational, not absolute. 
The evidence upon which our verdict is to be rendered is wholly 
circumstantial. Notwithstanding all this, and although cases 
sometimes occur, so enveloped in obscurity as to baffle the skill 
of the most careful and experienced observers ; it is still true 
that there are few general diseases, the diagnosis of which is so 
well established, and so certain, as that of typhoid fever. 1 

Perhaps, in the present state of science, a single qualification 
ought to be affixed to this last remark. The whole question of 
the diagnosis of the several individual diseases constituting the 
family of idiopathic or essential fevers, has been undergoing, 

1 A British reviewer of my book gravely cites this admission, of the occasional 
difficulty, or impossibility, of making an absolute and positive diagnosis, as suffi- 
cient proof that there is no specific difference between the typhm and the typhoid 
forms of continued fever — as though there could be no such individual disease? 
as cancer of the stomach, or softening of the brain, because we are not always 
able to make them out with entire certainty during life ! 



148 TYPHOID FEVER. 

ever since the publication of the work of Louis, a more rigorous 
and philosophical scrutiny than it had been subjected to before. 
Much of the chaotic confusion in which this question had always 
been involved has been cleared up. Diseases, which had occu- 
pied distinct and perhaps widely separated places in the nosolo- 
gies, have been shown to be identical; and diseases, on the other 
hand, have been shown to be widely different in their character, 
which had been regarded as identical. Some of these questions 
of difference and identity are still unsettled; they are matters not 
yet finally and definitively disposed of; not yet ranked amongst 
the established principles of medical science. One of the most 
important and interesting of these, and this constitutes the 
qualification which I wished to make, is that of the differences 
between the disease now under consideration and the true typhus 
fever. By many pathologists, the two diseases are considered 
to be essentially alike, identical. Until within a few years, this 
was the general opinion, and even now it is almost universally 
entertained by the British physicians, who have enjoyed the 
most extensive opportunities for studying and comparing the two 
diseases, or the two forms of disease, as the case may be. By 
other pathologists, these diseases are considered to be essentially 
and fundamentally unlike each other ; unlike in their nature, 
in their symptoms, in their pathology, and in the mode of 
management which they require. I believe this last opinion to 
be the true one ; but it cannot be satisfactorily discussed until 
both diseases have been described. For this reason I shall omit, 
in what I have now to say upon the diagnosis of typhoid fever, 
the consideration of the differences between it and the true British 
typhus. 

Setting aside then, as I do for the present, the true typhus 
fever, there is no disease more readily and positively recognized 
than a case of well-marked typhoid fever, of extreme or even of 
average severity, when observed from its commencement and 
followed through its entire course. It is hardly possible to con- 
found it with any other affection. There is no other in any con- 
siderable degree resembling it. Chills, more or less severe, 
repeated or not; accompanied with or immediately followed by 
headache, and pains in the back and limbs ; these pains subsiding 
and disappearing in the course of a few days ; thirst ; heat of the 
skin ; acceleration of the pulse, with an evening exacerbation ; 



DIAGNOSIS. 149 

entire loss of appetite : great muscular debility ; dulness and con- 
fusion of the intellect, passing gradually into delirium ; restless- 
ness ; vigilance, or somnolence ; twitching of the tendons, or 
picking at imaginary objects ; occasional epistaxis ; ringing or 
buzzing in the ears ; the appearance of a scattered, rose-colored 
eruption, principally upon the skin of the chest or abdomen, 
during the second week ; a dry, glutinous, cracked, red, brown, 
or blackish tongue, protruded with difficulty, and trembling ; dark 
thick sordes upon the teeth ; diarrhoea ; the stools thin, watery, 
and dark or yellowish, sometimes consisting of blood ; tym- 
panitic distension of the abdomen ; dulness on percussion over 
the spleen, and gurgling upon pressure upon the right iliac re- 
gion ; with a dry sibilant or sonorous rhonchus over the chest : 
these symptoms, coming on without any obvious cause, occur- 
ring usually in a person under forty years of age, and referable 
to no local disease ; more or less regularly and successively de- 
veloped ; increasing in severity, and terminating in death, at an 
indefinite period after the eighth day ; or gradually subsiding 
and disappearing one after another, and giving way to conva- 
lescence at an indefinite period after the fifteenth or twentieth 
day, mark most clearly and unequivocally a disease ivholly un- 
like any other. These symptoms are sometimes during the pro- 
gress of the disease, and in various degrees of relative severity, 
all of them present ; and in these cases, at any rate, there is no 
possibility of mistaking typhoid fever for any other disease. The 
diagnosis, independent of the evidence to be derived from the 
lesions found after death, in the fatal cases, is easily and cer- 
tainly made. 

In other instances, many of the foregoing, and amongst them 
some of the most characteristic symptoms, may be wanting ; and 
still the diagnosis may remain in no way difficult or doubtful. 
Some of the most serious disturbances of the nervous system 
may be absent. There may be no morbid watchfulness or drow- 
siness ; no aberration of the mind ; no twitching of the tendons ; 
but if the other symptoms above enumerated are present, there 
can be no uncertainty as to the character of the disease. Again, 
it may happen that the abdominal symptoms — the diarrhoea, and 
tympanitic distension may be wanting, without throwing any 
doubt upon the diagnosis. We may go further than this. Let 
us suppose that a person between the ages of fifteen and thirty 



150 TYPHOID FEVER. 

is attacked, without any appreciable cause, by the febrile symp- 
toms already repeatedly described ; attended or followed by loss 
of appetite ; sufficient prostration of muscular strength to confine 
the patient to his bed ; occasional epistaxis ; slight dizziness or 
ringing in the ears, at least on assuming the upright position ; and 
that these symptoms cannot be referred to any local disturbance, 
and persist for as many as twelve or fifteen days, with but little 
change, and not much influenced by medicine ; even under these 
circumstances there can be but little question as to the disease. 
In most cases, there will be found at least as many elements of 
diagnosis as in that just supposed ; in very many, there will be 
more. Almost always, the lenticular eruption will be discovered, 
if it is timely and carefully sought for ; if there is no diarrhoea, 
there may be slight distension of the abdomen, with gurgling on 
pressure over the region of the coecum ; or there may be deafness 
or sluggishness of the mind, or transient and wandering delirium, 
or, finally, some one or two of the numerous symptoms more or 
less characteristic of the disease. 

I do not mean to say by this that typhoid fever can always be 
distinguished with certainty from other diseases, even when it is 
watched during its whole course, and by the best observers. Un- 
questionably the disease is sometimes so nearly latent, or so poorly 
defined, as to be overlooked or mistaken ; but with ordinary know- 
ledge of its character, its symptoms, and their march, and with 
careful examination, this will very rarely be the case. 

It may happen not unfrequently, that the disease cannot be 
positively made out during the first few days after its access. 
The febrile symptoms, the chills, heat, thirst, accelerated circula- 
tion, with the pain in the head and limbs, are amongst the most 
prominent at this period, and they are those least characteristic 
of this disease. They are, indeed, common to the early period of 
this and of many other febrile affections, and of the local phleg- 
masia ; so that, until the subsequent and more distinctive and 
peculiar symptoms of the disease, whatever this may be, show 
themselves, it may not be possible to establish our diagnosis. In 
the same way, it may happen that the disease is not seen till it 
has reached its late stage. Many of its most important diagnos- 
tic characters may have disappeared, and no satisfactory history 
of its anterior progress can be obtained. Under such circum- 
stances, it may sometimes be confounded with other affections ; 



DIAGNOSIS. 151 

with dysentery in its late stages ; with some diseases of the brain ; 
and with local inflammations which are strongly marked, espe- 
cially near to their fatal termination, with what may be called 
the typhoid element in pathology. Louis once mistook a case of 
central softening of the brain, occurring in a boy, for typhoid 
fever. Erysipelas is often attended with many of the symptoms 
of this disease ; delirium, drowsiness, or stupor; red or brown and 
dry tongue, fuliginous teeth and gums, tympanites, and great 
prostration of strength, so that, were it not for the presence from 
the commencement of the cutaneous inflammation, it might some- 
times be confounded with typhoid fever. 

The diagnosis of typhoid fever in children is sometimes attended 
with considerable difficulty. The diseases with which it is most 
likely to be confounded, are gastro-intestinal irritation, accom- 
panied by fever, and meningitis. The following points of differ- 
ence between it and these diseases are enumerated by Barthez 
and Rilliet. Typhoid fever may be distinguished from gastritis. 
by the presence in the former of a greater degree of debility than 
usually attends the latter ; by a moderate agitation or delirium 
during the night ; by diarrhoea and gurgling on pressure over the 
ileo-ceecal region; by dulness on percussion over the region of 
the spleen ; by the rose spots and sudamina, at least in a large 
majority of cases; by more intense and prolonged febrile excite- 
ment ; and by the physical signs of bronchitis. From intestinal 
or gastro-intestinal irritation, it may be distinguished by the same 
signs, excepting the diarrhoea. 

The disease in children with which typhoid fever is more likely 
to be confounded than with any other, is meningitis. A careful 
attention to all the phenomena of the two diseases will, however, 
generally enable us to distinguish between them. In many cases 
the pulse is more rapid at the commencement of the disease in 
typhoid fever than it is in meningitis, although this difference is 
not sufficiently constant to be much relied upon. Spontaneous 
nausea and vomiting are more common in the latter than in the 
former ; and the headache is generally more severe. There is a 
very constant and striking difference in the state of the bowels ; 
in typhoid fever, there is diarrhoea ; in meningitis, there is con- 
stipation. The tongue is more frequently dry, brown, and cracked, 
and the lips and gums covered with sordes in the former than in 
the latter. The early stage of meningitis is more frequently at- 



152 TYPHOID FEVEK. 

tended by extreme agitation and delirium than that of typhoid 
fever ; and finally, the latter is more frequently accompanied by 
slight cough, and a dry sibilant rhonchus than the former. I 
may add that, while general convulsions are common during the 
middle and latter stages of meningitis, they seem to be very rare 
in typhoid fever, since Barthez and Rilliet met with them only 
twice in one hundred and eleven cases. 

Typhoid fever, like all other continued affections, is sometimes 
more or less mixed up with and influenced by the pathological 
element of periodicity. This will happen most frequently and 
will be most strongly marked in malarious regions, and during 
the prevalence of remittent and intermittent fever. Dr. Wooten 
of Lowndesboro', Alabama, in a letter to me, says: "I>may re- 
mark that I have often seen typhoid fever complicated with regular 
remittence — that is, typhoid fever and remittent fever existing 
together ; and I have cured the paroxysmal exacerbations, whilst 
the disease essential to typhoid fever continued ; and I have fre- 
quently found it necessary to do this, before the more formidable 
disease could be influenced by remedies. I have seen such cases 
in the practice of physicians, who supposed them to be remittent 
or bilious fevers, in which the bowels had become diseased as a 
consequence of the fever. I think this is a very common error. 
The malarial influence frequently so preponderates in the symp- 
toms of inflammatory diseases in our latitude, as to obscure the 
real disease for many days ; and in such cases it is easy to look 
upon such influence as the cause of the structural lesion, whilst, 
in fact, the latter has acted as the exciting cause to the manifesta- 
tions of the former." Dr. J. G. Core, of Williamson county, 
Tennessee, also in a letter to me, speaks of this same blending, 
occasionally, of the remittent element with typhoid fever. "Re- 
mittent fever," he says further, "will certainly run into a 
typhoid type, unless it is checked early before it becomes com- 
plicated; but that is far from being a case of true typhoid fever." 

I have said nothing, thus far, of the lesion of the elliptical 
plates, as an element in the diagnosis of the fatal cases. It has 
already been remarked that this lesion is characteristic of this 
disease, that it is invariably found in the fatal cases of typhoid 
fever, and that it is not found in fatal cases of any other acute 
disease. If this is absolutely true, without exception and without 
qualification, then the presence or the absence of the lesion ought 



DIAGNOSIS. 153 

to be final and decisive in regard to the diagnosis. Let us see 
what the evidence is upon this matter. I have already spoken 
of one case, which was regarded by Louis as typhoid fever dur- 
ing life. A post-mortem examination showed that the elliptical 
plates and mesenteric glands were healthy, and that death was 
the result of softening of the central portions of the brain. This, 
then, was manifestly not a case of typhoid fever. Not only were 
the usual lesions of this disease wholly wanting, but all the symp- 
toms and the fatal result were sufficiently accounted for by the 
cerebral lesion. This was a case of disease of the brain simulat- 
ing, to a certain extent, typhoid fever. And even here, it is but 
justice to say that Louis now considers his diagnosis to have been 
precipitate ; the diagnosis of a similar case occurring at the pre- 
sent time would, to say the least of it, be qualified and doubtful. 
Another case is recorded by Louis, in the first edition of his work, 
which was marked by most of the symptoms of typhoid fever, and, 
on examination after death, no lesion was found in the elliptical 
plates or the mesenteric glands. But here, again, it is important 
to remark that the case occurred in 1823, when the diagnosis of 
typhoid fever was more doubtful than it is at the present time ; 
and, furthermore, that the patient was not seen by Louis till the 
twentieth day of his illness. If to these circumstances it be added 
that there was extensive ancient disease of one of the kidneys, 
fatty liver, and considerable effusion under the arachnoid mem- 
brane, and into the lateral ventricles, certainly we arc justified in 
concluding, not that the case was one of typhoid fever, but that 
the diagnosis was incorrect. The second edition of Louis's work 
was published in 1841. In that, it is said that no single new 
case constituting even an apparent exception to the uniform re- 
lationship between the group of symptoms upon which the diag- 
nosis of typhoid fever rests and the abdominal lesion had then 
been met with, either by Louis himself, Chomel, or Bouillaud. 
One case is briefly reported by Fouquier, which occurred at La 
Charite', in 1833, in which the symptomatology of typhoid fever 
seems to have been pretty clearly marked, and in which the ellip- 
tical plates and the mesenteric glands were found almost free from 
disease. 1 A strong case of apparent exception to the law of re- 
lationship now under consideration is reported by Prosper Dor. 

1 Journal des Connaissances Medic ales, Jan. ISoi. 



154 TYPHOID FEVEK. 

It occurred at the Hotel Dieu of Marseilles, in 1833. The patient 
was eighteen years old, and died on the eighth day of the disease. 
There were these symptoms : headache ; debility ; loss of appe- 
tite ; sleeplessness ; then, epistaxis ; great prostration of strength ; 
soft, irregular pulse ; dry, blackish tongue ; sordes on the teeth ; 
meteorism ; diarrhoea ; delirium ; subsultus tendinum, and picking 
at the bedclothes. There was no cutaneous eruption. Certainly, 
in this case the diagnosis, during life, would have been sufficiently 
clear and positive. An examination after death showed the in- 
testines to be healthy, but it showed also extensive disease of 
the urinary apparatus. The mucous membrane of the bladder 
was incrusted with a layer of urate of lime, and in the left kid- 
ney there was a considerable number of purulent depositions. 
Now, when it is considered that diseases of these organs are very 
frequently attended, near to their fatal termination, with strongly 
marked typhoid phenomena, there can be no hesitation, I think, as 
to the disposition which ought to be made of the foregoing case ; 
no difficulty in assigning to it its proper position. It was clearly 
not typhoid fever ; but an instance of disease of the urinary appa- 
ratus, in which the typhoid symptoms, which often accompany 
the latter stages of the affections of this apparatus, were more 
numerous and more closely resembling those of typhoid fever 
than is often the case. Grisolle says that he has seen only a 
single exception to the relation of which I am speaking. 

I have been permitted, through the kindness of Dr. Hale and 
Dr. J. B. S. Jackson, of Boston, to look over the notes of a case 
which occurred in 1841 in the Massachusetts General Hospital, 
and which might seem to constitute an exception to this relation- 
ship. The patient was twenty-two years old. He entered the 
hospital on the 23d of June, 1841, after an illness of two weeks ; 
during the first half of which time he kept about his work. He 
had pain in the head, back, and limbs ; dizziness ; tinnitus 
auriurn ; prostration of strength; loss of appetite; daily spon- 
taneous diarrhoea; abdominal pain and epigastric distress ; 
tenderness over the right iliac region ; rigidity of the muscles 
and tympanitic distension of the abdomen ; epistaxis ; the rose- 
colored spots, and sudamina. He died on the eighth of August, 
having exhibited for some time symptoms of severe gastritis. 
The mucous membrane of the stomach was mammellonated, red, 
thickened, and ecchymosed; there was ulceration of the mucous 



DIAGNOSIS. 155 

membrane about the fauces and root of the tongue ; and the 
only alteration of the elliptical plates of the ilium consisted in 
their great distinctness, and perhaps a slight thickening, with a 
bright, spotted, ecchymotic redness of two of the plates; one of 
them two feet and the other four feet from the ileo-ccecal valve. 
One or two others were similarly affected, but in a slighter degree. 
A portion of the ileum nearly a foot in length, extending to 
within six inches of its lower termination, was deeply ecchymosed 
in bands running round the intestine. A single mesenteric gland, 
directly opposite to the ileo-ccecal valve, was nearly as large as 
the end of the thumb, red and soft. The other glands were 
scarcely at all enlarged. The spleen was of medium size. 

This case seems to me to be one of great interest, and suscep- 
tible of an obvious and ready explanation. The patient died of 
gastritis, eight weeks after the accession of typhoid fever. There 
is no evidence that the primary affection here was of unusual 
gravity ; there is no good reason to think that positive ulceration 
of the intestinal follicles usually takes place in mild cases, and 
perhaps not in many of moderate severity ; and in the one before 
us, supposing such to have been the case, sufficient time had 
elapsed from the commencement of the disease to account for 
the moderate degree of alteration in the elliptical plates and the 
mesenteric glands. It was a case of typhoid fever, I think, of 
moderate severity; the patient dying of gastritis, at so late a 
period that the enter o-mesenteric lesion had in good part, but not 
entirely disappeared. 

In the discussion of this question, great stress has been laid 
upon the observations of Andral, by those who deny or doubt the 
constancy of the connection between the diagnostic symptoms 
of typhoid fever and the peculiar lesion of the elliptical plates. 1 
A very cursory examination, however, of the facts cited by this 
distinguished writer, will show conclusively that they justify no 
such inferences as have been deduced from them, The cases 
which he has reported are fifteen in number. He arranges these 
in two classes : the first, consisting of cases of what he calls con- 
tinued fever with gastro-intestinal lesions, but without any altera- 
tion of the elliptical plates ; the second, consisting of cases of 
what he calls continued fever, without any appreciable lesion of 

1 Andral's Clinique Medicale, vol. iii., pp. 222 to 274, 2d ecL, Paris, 18o<X 



156 TYPHOID FEVER. 

the digestive tube. In the first class are contained the histories, 
generally short and incomplete, of seven patients. The fifth, 
sixth, and seventh are the only ones amongst them that can he 
considered even doubtful. The others are clearly enough not 
typhoid fevers ; in most of them there was not present even the 
typhoid state. The sixth case looks like the true petechial 
typhus, although the history of the patient is too imperfect to 
justify any confident diagnosis. The seventh case appears to 
have been one of pneumonia, complicated with erysipelas, follow- 
ing upon simple enteritis, and marked by typhoid phenomena. 
Certainly, there is not one amongst them which, with our present 
means of diagnosis, would be regarded with any degree of cer- 
tainty, before death, as a case of typhoid fever. 

An examination of the eight cases included in the second class 
is still more conclusive in its bearing upon the question now be- 
fore us. There is not one amongst them, the diagnosis of which, 
so far as typhoid fever is concerned, can be looked upon as even 
doubtful. It is hardly too much to say that neither of them 
could now be taken, by any possibility, for a case of typhoid fever. 
I will briefly enumerate the diseases. The first case, forty-sixth 
of the volume, was phlegmonous erysipelas of the arm, occurring 
in a soldier thirty-five years of age ; the second was gangrene of 
the right leg in a patient fifty-three years old, suffering with or- 
ganic disease of the heart ; the third was inflammation, either 
chronic or acute, of the right kidney and the mucous membrane 
of the bladder in a patient sixty years of age ; the fourth was ex- 
tensive suppuration of the prostate gland ; the fifth was latent 
pneumonia in a woman eighty-one years of age ; the sixth and 
seventh were affections of the brain, one of them in a patient 
eighty-one years old ; and the eighth was gangrene of the lip, 
accompanied with extensive phlebitis, and numerous purulent 
depositions in the lungs. This simple statement of these cases 
precludes the necessity of any further remarks upon them. Mani- 
festly, they have no connection with the question of relationship 
between the usual symptoms of typhoid fever and the alteration 
of the elliptical plates of the ileum ; and yet they have been, 
more perhaps than any others on record, relied upon to prove the 
want of any constancy in this relationship. It is certainly very 
important that this typhoidal state of the system, occurring in 
connection with many diseases, should be distinguished from 



DIAGNOSIS. 157 

typhoid fever. Unless this is done, there is an end to all positive 
and philosophical diagnosis. Since writing this history, I have 
seen a patient presenting these phenomena amongst others : pros- 
tration of strength ; slight subsultus tendinum ; tympanitic dis- 
tension of the abdomen ; diarrhoea ; gurgling on pressure ; a dry, 
red, cracked tongue ; sordes on the teeth ; wandering delirium ; 
and sudamina about the neck. Here were many of the most 
characteristic elements of typhoid fever; but the disease was 
clearly and unequivocally puerperal peritonitis. These typhoid 
phenomena, as I have already said, are often present in many 
diseases: in smallpox ; in scarlatina; in asthenic pneumonia; in 
softening of the brain ; in some diseases of the kidneys ; in ery- 
sipelas ; in dysentery, and so on ; but under these circumstances, 
where their connection with these several affections can be disco- 
vered, they ought not to be confounded with typhoid fever. It was 
from disregarding this obvious principle that Andral was led to 
the conclusion which I have been examining. 

Barthez and Rilliet, in the course of some observations on the 
disease as it occurs in children, published in the Journal des 
Connaissances Medico- Chirurgicales for 1841, report one or two 
apparent cases not attended by the characteristic lesion. 

There is one other point in the discussion of this question which 
it is important not to overlook. It has been said that these in- 
testinal lesions, strongly marked and striking as they may be, are 
by no means confined to cases of typhoid fever — that they are fre- 
quently found in other and quite dissimilar diseases; so that, ad- 
mitting even that they constitute the constant anatomical lesion 
of typhoid fever, they are still not distinctive and characteristic, 
since they are common to it and to other diseases. 

There is a single reply to these objections, which seems to me 
entirely satisfactory and conclusive. The diseases, other than 
typhoid fever, in which alterations of the intestinal glands are 
most frequently found, are tubercular phthisis, scarlet fever, and 
certain forms of cholera. Now in all these cases, it is quite suffi- 
cient to say that the condition of the glands is obviously and 
manifestly different from what it is in typhoid fever. In phthisis, 
the intestinal ulceration is clearly tubercular, depending upon the 
presence and development of this morbid product in the intestinal 
glands. Besides this fundamental difference in the very nature 
of the lesion, the inflammation and ulceration in phthisis are chro- 



158 TYPHOID FEVER. 

nic in their march, and the appearance of the lesions differs in 
many other respects in the two diseases. As to scarlet fever, and 
some of the forms of cholera, it is enough to say that the only 
changes of the intestinal glands observed in these diseases have 
consisted in a moderate thickening, with or without redness and 
softening of the follicles, and that even these changes are far 
from constant. In none of these diseases are there the peculiar 
changes of the intestinal glands found in typhoid fever, while the 
mesenteric glands are very rarely at all affected. 

In the consideration of this question, as of all others which 
are still legitimate subjects of discussion and controversy, I have 
sedulously endeavored to avoid anything like a partisan or one- 
sided examination. I have not intentionally overlooked or put 
aside, or warped to my mere wishes, if I have any such unfriend- 
ly and treacherous guides and counsellors in the search for truth, 
any of the evidence bearing upon the subject. I have adduced 
all the cases that I have been able to find which might seem to 
constitute exceptions to this general relationship, or to throw 
doubts upon its invariableness ; and the conclusion to which I am 
irresistibly led is this : That the connection between the diagnostic 
symptomatology of typhoid fever and the entero-mesenteric lesions 
is, I will not say absolute and invariable, but as nearly so as the 
connection between the diagnostic symptoms and the characteris- 
tic lesions of any given disease whatever in the nosology, in 
which this connection is not established by positive physical 
signs. 



159 



CHAPTER IX. 

THEORY. 

I believe that it will be a phenomenon in medical -writings to find an essay on 
such a disease as fever unattended by a theory of its proximate cause. Yet were 
it as well if the professor who spends months in exciting the wonder or applause 
of a juvenile audience with phraseology which he does not himself understand, 
would substitute, for all this waste of words and time, the confession of his own 
and the general ignorance.—- John Macculloch. 

The most positive thing that can be said under this title is, 
that the materials for a complete and philosophical theory of 
fever, or theory of any individual fever, using this phrase in its 
ordinary acceptation, do not exist. Such a theory presupposes 
and involves a knowledge of the intimate processes and relations 
of the living powers which has not yet been attained. It is very 
questionable even whether such knowledge is attainable. 

In order to see clearly the truth of these observations, and the 
extent of this truth, let us inquire for a moment what some of 
the elements are which must go to make up this knowledge ; 
what their nature is, and in what they consist. In the first 
place, we must know what the actual efficient causes of any 
given fever, or form of fever, are. We must know what that 
agency or combination of agencies is, which, being present, 
brings into existence, originates, sets in motion that concatena- 
tion of disordered actions, that complex combination of morbid 
processes, which constitutes the fever. We must know in what 
manner these agencies act ; where they make their impression ; 
and in what the modifications consist which they work in the 
living Organization and its properties. Of all these things, we 
are utterly and profoundly ignorant. In the second place, we 
must know the seat and character of all these processes and modi- 
fications themselves ; their peculiarities ; their tendencies ; the 
differences which exist between them in the several forms of 
febrile disease. We must know their relations to each other. 



160 TYPHOID FEVEK. 

We must know which amongst them are primary and essential ; 
which are secondary and accidental. We must know the parts 
which they severally play in the production of the integral dis- 
ease. Of these things, also, as of the causes of fever and their 
mode of action, it is not too much to say that, if we are not 
wholly and profoundly ignorant, we are so to a great extent. 
They are but very partially and imperfectly known to us. They 
are known to us rather analogically, if I may so speak, and by 
comparison with other morbid processes, than absolutely and 
positively. We can see wherein they differ in many respects 
from these other processes, and wherein they resemble them. 
With these limitations, and under the conditions implied by these 
remarks, there is no reason why we may not attempt to com- 
mence the foundation of a theory of fever. But in the present 
state of science, it can only be an attempt at a commencement. 
We may endeavor to interpret the connection and relationship 
which observation has shown to exist between certain phenomena 
or groups of phenomena. We can do nothing more. 

It ought to be unnecessary to say that even this can be done 
only by confining ourselves to a single well-defined individual 
form of fever. Under the simplest conditions, and where alone 
it is in the nature of things at all possible, we shall find this in- 
terpretation or theory sufficiently obscure and difficult. When 
attempted as has generally been the case under other conditions, 
it has proved utterly futile ; when applied, as these interpretations 
and theories have generally been applied, to unascertained and 
imaginary states of the system, they have always degenerated, 
necessarily, into the idlest of all conceivable speculations. There 
is no such individual disease as that which has always been ex- 
pressed, and which is still expressed by the term fever. How 
then can there be any theory of fever ? There a»e many separate 
diseases, to which this generic name is properly enough applied, 
on account of certain general analogies which exist between them. 
But the disordered actions and processes which constitute one of 
these diseases may differ essentially ; and, as far as we can ascer- 
tain, in most cases they do so differ from those which constitute 
another of these diseases. The theory of one fever, then, must be 
wholly or to a great extent inapplicable to another. The elements 
which enter into the composition of one problem are not to be 
found in the other, or they are present in different proportions. 



THEORY. 161 

The word fever, when used as it commonly is to designate a dis- 
ease, has no intelligible signification. It is "wholly a creature of 
the fancy ; the offspring of a false generalization and of a spurious 
philosophy. What, then, can its theory be but the shadow of a 
shade ? 

If the true theory of disease be such as I have represented it, 
we should naturally look in its application to any individual and 
separate form of disease, first and principally to those phenomena 
which are most constantly present, and which seem to constitute 
its most important elements. According to this rule, and in rela- 
tion to the subject immediately before us, the theory of typhoid 
fever, the first inquiry would naturally be, what is the nature and 
what are the relations of its characteristic lesion — that of the 
elliptical plates of the ileum ? A satisfactory answer to these 
questions would so far settle the theory of the disease. 

What is the nature of this alteration of Peyer's glands? Does 
it consist in an inflammatory action, and its results? If so, is the 
inflammation common and simple ; or has it something peculiar 
and specific in its character? We can hardly hesitate, I think, 
in attributing this lesion to inflammation. We know nothing of 
any other morbid process that can produce similar results. In 
its early stages, we find the tissues which are its seat tumefied 
and reddened ; subsequently, ulceration takes place ; and if life 
is not destroyed, there is abundant evidence that the restorative 
process is set up and the lesion removed by complete cicatriza- 
tion. Their enlargement, softening, redness, and in some in- 
stances the presence of pus in their substance, are equally suf- 
ficient proofs that the affection of the mesenteric glands is also 
of an inflammatory character. But as to the second point, it 
seems to me that all the analogies in pathology tend to show- 
that this inflammation is not common, but specific. It is circum- 
scribed, and not diffused, as ordinary inflammation of the mucous 
tissues usually is. It does not often lose itself gradually, shading 
off into healthy membrane. The morbid process almost constantly 
extends to the subjacent cellular membrane, which is almost never 
the case in common mucous inflammation of an acute character. 
Its tendency to rapid ulceration, and the appearances of some of 
its morbid products, would also seem to show that it has some- 
thing special and peculiar in its nature. Is it not also philosophi- 
cal and fair to infer something in corroboration of these views 
11 



162 TYPHOID FEVER. 

from the observations of Andral and Gavarret in regard to the 
condition of the blood in different diseases? They have found, 
from extensive and careful examination, that, in all diseases con- 
sisting of common, open, frank inflammation in any of the organs, 
or complicated with such inflammation, the relative quantity and 
proportion of fibrine in the blood are increased ; while in diseases 
of an opposite character, and under opposite circumstances — in 
the exanthemata, for instance — the fibrine either merely main- 
tains its natural proportions, or is diminished in quantity ; a con- 
dition, as we have already seen, characteristic of the blood in 
typhoid fever. 

In regard now to the relation between this lesion of the ellip- 
tical patches on the one hand, and the disease considered as a 
whole on the other, or between the lesion and the symptoms, 
the simplest view to be taken is that which makes the disease 
consist essentially in the lesion, and which refers the symptoms 
to the lesion as their cause. This doctrine makes typhoid fever, 
not an essential or idiopathic fever, but an enteritis, or a follicular 
enteritis, or a dothinenteritis, and assigns to it a nosological posi- 
tion amongst the local phlegmasia. This is a modification merely 
of the great doctrine of Broussais, and a modification only so far 
that it does not include the mucous membrane of the stomach in' 
the lesion. It is still held, partially at least, by some French 
pathologists of the present day. It has been, strangely and un- 
accountably enough, even by men who have read his books, 
attributed to Louis. Dr. O'Brien, of Dublin, in one of his hos- 
pital reports, when speaking of this subject, says : " M. Louis, 
in particular, has adopted the theory of Broussais in its fullest 
extent." 1 The same misapprehension has been fallen into even 
hj such a man as Dr. Christison. It is, however, so far from 
being true that Louis has ever adopted the doctrine of Broussais 
in relation to the nature of fevers, that no other observer has done 
so much in overthrowing his peculiar principles. He has ever 
been the most formidable and successful antagonist of that extra- 
ordinary man ; opposing, in the calm confidence of a truth-loving 
and truth-seeking spirit, to the arrogant assertions and to the 
seductive generalizations of the highest genius — maintained and 
vindicated as they were by a strength and an eloquence of lan- 

1 Dublin Med. Trans., p. 313. 



THEORY. 163 

guagc unequalled in the annals of medical literature — the im- 
pregnable and serried array of facts and their relations, carefully 
and positively ascertained. One objection to this view of the 
nature of typhoid fever consists in the circumstance that there 
is no uniform proportion between the extent of the local disease 
and the severity of the symptoms. There are many fatal cases in 
which the intestinal lesion is very limited in extent; there are 
others, where the whole character of the disease has been unusu- 
ally mild, and in which, when life has been destroyed by some 
secondary and accidental complication, the alteration of the in- 
testine has been found to be very extensive and profound. This 
objection, although sound and reasonable, ought not to be consi- 
dered conclusive. Notwithstanding the exceptions just referred to, 
it is not certain that there is not, after all, a general correspond- 
ence between the gravity of the local lesion and the severity of 
the disease. Besides, even in affections manifestly of a strictly 
local character, in which the disease consists in the local lesion, 
it is far enough from true that there is anything like an exact 
and uniform proportion between the extent of this lesion and the 
general disturbance of the economy. The degree of this dis- 
turbance, constituting the general symptomatology, is influenced 
by a variety of causes other than the local disease; so that, 
although we shall find abundant reason, I think, for rejecting the 
view of which I am speaking, let us be careful not to do so for 
false reasons, and on wrong grounds. 

I shall now allude to some of the considerations which go to 
show that the local lesion of typhoid fever is not primary, but 
secondary ; that, instead of being the single cause and origin of 
the disease, it constitutes only one of its elements, and is itself 
dependent upon some other and ulterior morbid condition as its 
cause, the seat, nature, and operation of which are not known to 
us. It may be observed that, if the view which has been taken 
of the specific character of the inflammation, entering into the 
composition of the follicular lesion, be looked upon as sound, it 
constitutes, in itself, a cogent reason for the correctness of the 
doctrine above stated. Indeed, it must constitute the principal 
reason ; and, in addition to what has already been said upon this 
subject, I will only present one other consideration, which has 
been much insisted upon, in support and illustration of the view 
before us, by Chomel. He says that one of the most constant 



164 TYPHOID FEVER. 

and uniform characteristics of secondary lesions, consisting gene- 
rally of specific inflammations, is the fact of their being dissemi- 
nated ; of their occupying numerous and circumscribed spots in 
the tissues and organs of the system. The most striking exam- 
ples of this pathological law are to be seen in the eruptive- fevers ; 
in measles ; scarlatina ; smallpox ; and the oriental plague. The 
same law shows itself, also, in other cutaneous inflammations ; in 
urticaria; in varicella; in the successive crops of furuncles, which 
are sometimes observed, and so on. It is seen, further, in some 
affections of a different character ; such as scrofula, syphilis, and 
the several varieties of scirrhus and cancer. All these numerous 
diseases, though they differ very widely from each other in many 
respects, have this character in common ; that the local inflam- 
mations which accompany them are disseminated ; that they oc- 
cupy a considerable number of defined and limited localities. 
There are several other particulars in which the members of this 
extensive family of disseminated lesions agree with each other, 
all of which tend to exhibit their specific character, and their sub- 
ordinate relations. They depend upon specific causes. They 
cannot be produced at will by any of the ordinary excitants of 
common inflammation. In many cases, these causes are gene- 
rated by the morbid process itself ; and so the diseases are trans- 
mitted directly from one individual to another, and are thus per- 
petuated. In other cases, the origin of the cause is unknown. 
They have generally a more or less regular march and determi- 
nate duration, in many instances going through a series of suc- 
cessive stages, and, if life is not destroyed in the course of the 
process, terminating naturally in a return to a healthy condition. 
This march and duration are but very little under the control of 
art ; the first cannot be much modified, nor the second much 
abridged by the use of remedies ; and so far even as these effects 
can be produced, they must be produced by means acting, not 
directly upon the lesions themselves, but upon the general system. 
Now, in every respect, the intestinal lesion of typhoid fever corre- 
sponds to this class of pathological alterations. It is disseminated ; 
occupying the same glandular tissue at different points of the in- 
testinal mucous surface ; it cannot be artificially produced by any 
of the common causes of inflammation ; it depends upon a specific 
but unknown cause; it has a regular march and a determinate 
duration ; passing through its several stages, and terminating, if 



THEORY. 165 

life is not destroyed, in a return to health ; and, finally, this pro- 
cess is but little under the control of art. It is strongly corro- 
borative of the soundness of this view that, in a disease closely 
resembling this in many of its symptoms, I mean the contagious 
typhus, there is no constant local lesion of any sort to which the 
symptoms can be referred. Certainly, it needs no elaborate 
argument to show how clearly all these circumstances indicate 
that the local lesions in this class of diseases are peculiar in their 
nature, secondary and dependent in their relations, constituting 
not the primary and essential cause, but only one of the patho- 
logical constituents of the particular diseases in which they seve- 
rally occur. 

Some pathologists have adopted the doctrine that the unknown 
cause of typhoid fever acts primarily upon the nervous system, 
producing some unascertained lesion of innervation, which, in its 
turn, gives rise to disturbances and alterations in the other or- 
ganic apparatuses and tissues, and in the fluids ; these aggregate 
disturbances and alterations constituting the disease. This doc- 
trine may be the true one ; but in the present state of science it 
must be regarded as wholly hypothetical ; and there are some 
considerations which militate strongly against its probability. 

Another theory is that which places the primary and funda- 
mental alteration in the blood. We may be justified, I think, in 
saying that at least this theory has more claims upon our atten- 
tion, and is more probable, than that of which I have just spoken. 
It is already demonstrated that, in many cases of typhoid fever, 
and in other diseases to which it is more or less nearly allied, 
especially by the common presence in them all of what has been 
called the typhoid state, or the typhoid element in pathology, im- 
portant and peculiar changes have taken place in this fluid. 
These changes may have been primary and essential. There is 
good reason to think, at any rate, that they play a very important 
part in the pathology of these diseases. They deserve further 
investigation, and they ought never to be overlooked ; but their 
actual relations to these diseases are very far from being ascer- 
tained. In another class of affections, the acute phlegmasia, 
we find important alterations in the composition and character 
of the blood, which are pretty evidently the result of the dis- 
ease ; they are secondary and not primary in their relations. 
Such may be the case, also, in typhoid fever, and its analogous 



166 TYPHOID FEVER. 

diseases. I am disposed to look favorably upon this partial re- 
turn of the old humoral pathology, and to hope much from its 
cultivation and development ; but I do not think that we can yet 
apply it very confidently or extensively to the interpretation of 
morbid phenomena. This upon the whole, it seems to me, is as 
far as we can go, safely and philosophically, in our attempt to 
explain and to account for the morbid processes and alterations 
which constitute typhoid fever ; or to establish, in other words, 
a theory of the disease. 



167 



CHAPTER X. 
TREATMENT. 

There are few diseases of equal frequency and importance, 
the treatment of which, is more unsettled than that of typhoid 
fever ; and there is certainly no disease, 'the therapeutics of 
which has, within the last few years, attracted more attention 
than this. Various, and to some extent opposite modes of 
management have been adopted by different practitioners ; they 
have been conducted on a large scale, for the most part in a fair 
and impartial spirit, and under circumstances favorable to the 
discovery of the truth ; but they have not yet resulted in the es- 
tablishment of any uniform and satisfactory method of treat- 
ment. There is no unanimity in the opinions and conduct o 
different practitioners. 

Under these circumstances, it is somewhat difficult to decide 
upon the best course to pursue, in treating of the subject, in 
work like the present. It is impossible, within any reasonable 
limits, to describe in detail all the different plans of treatment 
that have from time to time been adopted, or that are still pur- 
sued, together with their actual or alleged results. Still, the 
completeness of the work and the interests of humanity alike 
require that the actual state of our science in this respect, the 
sum and the result of our observations and researches, so far as 
these can be ascertained, should be fully and fairly stated. I 
shall therefore endeavor to do this, as far as it is possible. I 
shall describe the several modes of management which have been 
most extensively followed, and most thoroughly studied, by those 
leading and distinguished men who have been most favorably 
situated for the investigation of this subject. In doing this, I 
shall not often enter into any detailed and particular statement 
of the effects of individual remedies in single cases, or upon 
single symptoms which different physicians allege that they have 
seen produced. It will be sufficient for my purposes to state, in 
general terms, the results of their investigations and analyses. 



168 TYPHOID FEVER. 

/ 

ARTICLE I. 

DR. JACKSON'S METHOD OF TREATMENT. 

Dr. Jackson, of Boston, after having been for many years an 
extensive and careful observer of typhoid fever, both in public 
and in private practice, and after an accurate and circumstantial 
re-examination and analysis of the effects of remedies upon the 
disease, as they were exhibited in the wards of the Massachusetts 
General Hospital, arrives finally at the following conclusions, 
which it is impossible to give so well in any other way as in 
his own words. They would suffer by any alteration or abridg- 
ment. 

" First, that, on the attack of this disease, the patient should 
immediately desist from labor and mental exertion, abstain from 
food, except of the simplest liquid kind, and place himself in bed, 
or at least in a state of repose. 

" Second, that free evacuations should be made at the begin- 
ning, and that, in doing this, a day is important. It is better 
that they be made the first day than the second, better on the 
second than the third ; but that it is especially important that they 
should be made as early as the third day. That an emetic of 
tartarized antimony should first be given, and then an active 
cathartic, or the two in combination. If there is constipation at 
the time, an active enema, given at first to disembarrass the 
bowels, would no doubt facilitate the action of an emetic. If the 
vomiting and purging are not followed by great relief, venesection 
should be practised on the following day, unless the constitution 
should be very feeble, or the case very mild. 

"Third, if the disease has not subsided after the evacuations, 
tartarized antimony should be given every two hours in increasing 
doses, after the method of Odier of Geneva. Meanwhile, the 
bowels should be kept open, and, for two or three of the first days, 
it would be well that calomel should enter into the medicine used 
for this purpose; not, however, giving more than one moderate 
dose in a day. It should be noted, however, that usually, after 
the antimony has been given for forty-eight hours, this will act 
sufficiently on the bowels> and that sometimes it must be restrained 
by opium. 



TREATMENT. — DR. JACKSON'S METHOD. 169 

"Fourth, that, when the disease subsides early under any 
active treatment, it is quite essential that the patient should be 
restrained from solid food for two or three days, at least, after he 
has an appetite for it ; and that he then use vegetable food in 
small quantities, for two or three days more. Likewise, that he 
should not be allowed to make any efforts of either body or mind 
until his convalescence is fully established. By this, it is not 
intended that he should be confined wholly in bed, but that he 
should be confined to his chamber, and not allowed to talk on 
business, nor on any interesting subject. 

" Fifth, that evacuations, vomiting and purging at least, may 
be resorted to with advantage in the second week ; and that per- 
haps some benefit may be obtained from antimony in small doses, 
when commenced in that week. But that, after that period, no 
active treatment should be employed, or none which will cause 
any serious inconvenience to the patient. 

" Sixth, as to diet. There is no point probably on which all 
practitioners are more agreed than that food should be withheld 
from persons affected with the disease in its early period, except 
only the mildest or most bland liquid articles. Probably food 
would be injurious in its early period, at least, if it could be 
digested. But it cannot be digested perfectly, and often not at 
all, and that alone should forbid the use of it. When the disease 
is arrested or mitigated by treatment, it is very certain that an 
indulgence in the use of food is most commonly injurious, and 
that the cautions already stated are not too severe. When, how- 
ever, the patient is fully reinstated, he must be allowed some extra 
food for the recovery of his flesh and strength. This must be done 
cautiously ; but an extreme and protracted abstinence is injurious. 
When the disease runs its usual course, and the appetite for food 
returns, is there any danger in the indulgence of it ? To this 
question I answer, in proportion as the return of appetite takes 
place early, more caution is necessary. If it takes place at or 
about the end of the third week of the disease, if it is decided, and 
if it is accompanied by a cleaning of the tongue, almost any arti- 
cle which the patient craves may be allowed him with safety. 
The appetite is usually a sufficient guide as to the quality of the 
food ; but not as to quantity. In a large proportion of cases, it 
will be found a most uncertain guide as to quantity. Hence it 
is necessary to begin with small quantities, and to increase gra- 



170 TYPHOID FEVER. 

dually. It is equally necessary to make the intervals long between 
the portions of solid food, which are given in the early period of 
convalescence. At first, there should be one portion of solid food 
in the day ; the next day, if everything is favorable, two portions, 
with five or six hours between them ; and two or three days later, 
watching the effects, three meals may be allowed. But we are 
not merely to feel the pulse under these circumstances, to see if 
the fever has increased. The danger is not, I apprehend, that the 
system will be too suddenly nourished. It is that the enfeebled 
organs of digestion may not be able to digest the food. We must, 
therefore, watch all the signs which refer to those organs. Only, 
if the head should ache, or other organs be disturbed, we should 
remember that the prominent signs of indigestion are often shown 
elsewhere than in the stomach, and stop the food till it appears 
whether this is not now the case. It is also to be constantly re- 
membered that constipation of the bowels will be followed by 
indigestion, and that evil must, therefore, be guarded against. 

" Seventh, cordials. On this, as under the last head, I must 
give the convictions arising from the most careful observations I 
have been able to make in many years. I cannot adopt the more 
accurate mode of the numerical system. Nor in this case could 
this system be usefully followed, unless with the greatest atten- 
tion to the state of each case. It has appeared to me that we 
should not adopt the rule to give cordials, nor to withhold them, 
in every case. When a patient is induced to take cordials re- 
luctantly,, they seldom benefit him, and are often followed by 
injury. When he is greatly enfeebled, at a late stage of the dis- 
ease, he may be safely asked if he wishes for them, and if he does 
he may try them ; they will seldom hurt him then, if he takes no 
more than is grateful to him. When he spontaneously demands 
them, as late as the third week, they will almost always be found 
useful. Now in following these rule.s, I have occasionally found 
a patient who would take a large quantity of some cordial liquor. 
But this has been rare. Few take them longer than two or three 
days, and the majority of patients do not take them at all. It is 
proper to add that by cordials I mean vinous liquors. I have 
most commonly found cider grateful in the first instance, begin- 
ning with an ounce, two or three times a day, and increasing ac- 
cording to the effects. Sound beer or ale is more rarely but 
sometimes grateful. In patients much exhausted, however, the 



TREATMENT. — DR. NATHAN SMITH'S METHOD. 171 

strong foreign wines, Sherry, Port, and Madeira, are found most 
useful. These articles may be diluted, or may be employed to 
season articles of diet, or may be given alone, according to the 
taste of the patient." 1 

It may be added here that Dr. Jackson, during the early period 
of his practice, in common with most of the New England physi- 
cians, made use also of calomel in the treatment of typhoid fever. 
This article generally made a part of the purgative given at the 
commencement of the disease. 

It was afterwards continued in small and frequently repeated 
doses, combined, according to circumstances, with ipecacuanha, 
or antimony, or opium. Moderate ptyalism was looked upon as 
a favorable occurrence, although profuse salivation was dreaded. 
Dr. Jackson's faith in the usefulness of calomel was shaken a 
few years after the commencement of his practice ; when the 
Massachusetts General Hospital was opened, he still resorted to 
it occasionally, during the first few days of the disease, and par- 
ticularly when any secondary inflammation supervened ; but con- 
fidence in the specific power of the medicine grew less and less, 
and, since 1830, its use in the hospital has been nearly abandoned. 
Dr. Jackson informs me that his convictions of the efficacy of 
early evacuations in the treatment of typhoid fever, founded on his 
experience in private practice, are not less strong than those 
which rest on the careful analysis which he has made of the 
results of his hospital cases. 

ARTICLE II. 

DR. NATHAN SMITH'S METHOD. 

I shall now give a summary of the mode of management fol- 
lowed in typhoid fever by the late Nathan Smith. He begins 
his remarks on the treatment of this disease by saying that he 
had never seen a single case in which he was satisfied that he 
had been able to cut short and arrest its progress ; and that, in 
all cases where the disease is going on regularly in its course, 
without any symptom denoting danger, and without any local 

1 Dr. Jackson's Report on the Typhoid Fever, Med. Com. of the Mass. Med. 
Soc, vol. vi. part ii. p. 168, et seq. 



172 TYPHOID FEVER. 

distress, active interference will be likely to do more harm than 
good. Under such circumstances, he thinks no medicine should 
be given. He also expresses his conviction that all powerful 
remedies or measures made use of in the early stage of the dis- 
ease are very liable to do harm, and that those patients who are 
treated with them in the beginning of the fever do not hold out 
so well in its latter stages. He says that he has seen many 
cases in which persons in the early stages of this disease were 
moping about, not very sick, but far from being well, and who, 
upon taking a dose of tartrate of antimony, have been immediately 
confined to their beds. 1 He adds in another place these remarks : 
" In cases of simple mild typhus, where there is no nausea at the 
stomach, no pain in that region, where the heat is moderate, and 
the pulse not greatly altered in frequency, I am clearly of opin- 
ion that we had better leave the disease to cure itself, as reme- 
dies, especially powerful ones, are more likely to do harm than 
good. In such cases, the patient gets along better without 
medicine than with ; all that is required is to give him simple 
diluent drinks, a very small quantity of farinaceous food, and 
avoid as much as possible all causes of irritation." 

Dr. Smith opposes the plan, then adopted by some New Eng- 
land practitioners, of general and almost indiscriminate blood- 
letting, at the commencement of the disease. He would bleed 
only where there was "uncommon pain in the head, accompanied 
with great heat in that part, a sense of fulness, and a throbbing 
of the temporal arteries ; or marks of congestion in the viscera of 
the thorax, such as pain in one or both sides of the chest, increased 
by a full inspiration." Under these circumstances, he thinks 
that the loss of from twelve to sixteen ounces of blood will often 
mitigate the severity of the disease, and enable the patient to go 
through it with more safety. The immediate effects of bleeding 
have not appeared to him very obvious ; and he says that, where 
the pulse is very frequent, the operation is seldom or never at- 
tended with any advantage. 

Emetics are recommended by Dr. Smith only where there are 
nausea and oppression at the stomach, either at the commence- 
ment or during the progress of the disease. His favorite articles 
are ipecacuanha, eupatorium, or sulphate of zinc, given either 

1 Smith's Medical and Surgical Memoirs, p. 72, et seq. 



TREATMENT. — DR. NATHAN SMITIl'S METHOD. 173 

singly or combined. Tartrate of antimony he looks upon as an 
inappropriate and unsafe remedy. The bowels, he says, should 
be kept open with gentle laxatives, but active and indiscriminate 
purging he considers hurtful. Blisters, according to his experi- 
ence, sometimes relieve local pains, and are sometimes injurious. 
They may as well, he thinks, be generally dispensed with. 
Stimulating remedies given internally, with external heat, for the 
purpose of exciting active perspiration, have always appeared to 
him to be attended with bad consequences, at all periods of the 
disease. Opium, for the purpose of procuring rest and quietness 
during the night, when it is not contraindicated by high febrile 
excitement and pain in the head, and in combination with ipeca- 
cuanha and camphor, to restrain immoderate diarrhoea, he says, 
may be used to advantage. He has seen in many instances very 
serious evils from the specific action of mercury, but no benefit. 
Cinchona he has found to produce a good effect in some cases 
where the surface was cold, and also where there was hemorrhage. 
The mineral and vegetable acids, the alkalies, refrigerants, as 
they are called, such as sulphate of magnesia, super-tartrate and 
nitrate of potass, he regards as unimportant or questionable re- 
medies. 

The most effectual refrigerant and febrifuge, in the hands of 
Dr. Smith, consisted in the free use of cold water externally. 
He is very warm and decided in his commendation of this re- 
medial measure. He says that there is nothing else so powerful 
in allaying morbid heat of the surface, in diminishing thirst, and 
in quieting restlessness and agitation. He directs the body of the 
patient to be uncovered, and then to be sprinkled or dashed re- 
peatedly with pure cold water. He allows cold water for drink, 
as freely as the patient may desire, during the whole course of 
the disease. 

Dr. Smith closes his account of his expectant and rational sys- 
tem of treatment in typhoid fever with the following directions 
for the general care of the patient : — 

" When an individual is first taken sick with typhous fever, we 
should expect a disease of considerable length, and make our ar- 
rangements accordingly. If the thing is practicable, he should 
be kept in a spacious room, the larger the better. His bed should 
be of straw, or husks, especially if it is in the warm season ; and 
it should not be placed in the corner, but brought out into the 



174 TYPHOID FEVER. 

room. We should contrive to have a current of air pass over the 
bed by means of doors and windows. * * * In the warm season 
of the year, the windows should be kept open night and day. 
All the furniture should be removed, except such articles as are 
required for the patient's use. The windows should be darkened, 
or something opposed to the light, in such a way as to still admit 
the air. The room should be kept as quiet as possible, since 
noise is injurious, and no more persons should be admitted than 
are necessary to take care of the patient, which will, if he is very 
sick, require the labor of more than one. 

"The room should not be carpeted, and the floor should be 
often washed with pure water, or soap and water; and in the hot 
season, it, as well as the walls, may be kept wet with water dur- 
ing the heat of the day. 

" Cleanliness is absolutely essential to the patient's comfort, 
and no dirty dishes or useless medicines or food should be suffered 
to remain in the room. All excrementitious matter should be 
removed immediately. In the warm season of the year, the bed 
and body linen should be changed every day, and in the cold, 
every other day at farthest. 

" The patient's body and limbs should be cleansed every day 
with a piece of sponge and warm water, or soap and water. If 
a male, he should be shaved every day or every alternate day, 
and if a female with long thick hair, it should be cut off or thinned 
so as to leave but little of it the full length." 1 

ARTICLE III. 

chomel's METHOD. 

The treatment of typhoid fever has been, especially for the 
last twenty years, a subject of great interest amongst the physi- 
cians of the large hospitals of Paris. It was in these institutions 
that the symptomatology, diagnosis, and pathology of the disease 
were first thoroughly studied ; the opportunities which they offer 
for a careful trial and comparison of different modes of manage- 
ment are unequalled ; and these opportunities have been very 
faithfully made use of by a considerable number of cautious, accu- 

1 Smith's Medical and Surgical Memoirs, pp. 95, 96. 



TREATMENT. — CHOMEL'S METHOD. 175 

rate, and philosophical observers. Amongst them may be men- 
tioned, particularly, and this without making any invidious dis- 
tinction, Chomel and Louis. Chomel has been for many years 
attached either to La Charite* or to the Hotel Dieu ; he has 
grown old in the constant and conscientious study of disease ; 
and now, in the ripe maturity of age and experience, is unsur- 
passed, in the capital of France, as a man of practical sagacity 
and skill. I shall first give a summary of his practice in this 
disease. 1 

His treatment is for the most part what is called rational or 
symptomatic ; that is, it is adapted, as far as common sense and 
experience enable us to do this, to the varying state and condition 
of the patient in different forms of the disease, and in the several 
stages of its progress. 

Simple and benign cases may be very safely trusted, he says, 
to refreshing drinks, such as lemonade, currant water, orange 
water, or pure water, taken at short intervals, and in such 
quantities as the patient may desire ; emollient fomentations or 
poultices upon the abdomen,' when this is painful ; sponging the 
surface of the body with vinegar and water, or cold affusions, if 
the skin is hot ; mucilaginous injections, several times a day ; 
cold applications to the head, when this is the seat of pain, and 
hot poultices or sinapisms, if there is a disposition to drowsiness 
and disturbed sleep. These measures, combined with fresh air, 
cleanliness, and quiet, will generally conduct the patient safely 
through this form of the disease. Still, Chomel is inclined to 
think that, even in these cases, a single moderate bleeding at the 
commencement of the fever, while it diminishes somewhat the 
severity of the headache and shortens the period of its continu- 
ance, may also be of some utility in preventing the development 
of ulterior complications, and exert some favorable influence upon 
the march and termination of the disease. If the headache or 
the pains in the abdomen are severe, leeches may be applied 
below the mastoid processes for the former, and near the anus 
for the latter. If the bowels are constipated, they may be 
opened by some gentle laxative ; if the diarrhoea is troublesome, 
it may be moderated by rice water, injections of starch and water, 
and so on. 

2 Le^ns de Clinique Medicale. Par A. F. Chomel. p. 449, ei .scq. 
I 



176 TYPHOID FEVER. 

In the inflammatory form of the disease, Chomel adopts a 
more decided antiphlogistic course, adapted to the intensity of the 
symptoms and to the age and vigor of the patient. The bleed- 
ing is to be repeated once or twice, leeches applied where they 
are indicated, and an entire abstinence, even from liquid nourish- 
ment, enforced upon the patient. When the disease is marked 
by bilious symptoms, a yellow fur on the tongue, a bitter taste, 
nausea, vomiting of bile, and constipation, the same general 
course is to be pursued as in its simple form. Chomel has not 
often resorted, even under these circumstances, to the use of 
emetics, since he has generally found that the symptoms just 
enumerated have subsided under the simple hygienic treatment. 
He thinks, however, that in some of these cases, where the dis- 
ease comes on suddenly, and there is reason to suppose that the 
stomach may be oppressed by its contents, an early emetic would 
be useful. Chomel' s mucous variety of typhoid fever is too in- 
distinctly marked to make it necessary to notice the slight modi- 
fications of treatment which he thinks it may require. In the 
ataxic form of the disease, there are no uniform rational indica- 
tions. If it is attended with highly inflammatory symptoms, 
the active antiphlogistic course is to be pursued; if it is attended 
with great debility, tonics and cordials are to be given. 

In the adynamic form of the disease, Chomel adopts a decided 
tonic and stimulant treatment, adapted in activity to the degree 
of prostration and debility. He speaks with great confidence of 
the propriety and necessity of this course, in these cases. Where 
the failure of muscular strength is extreme, indicated by the dif- 
ficulty and languor of all the voluntary motions ; the feebleness 
of the voice ; the sinking of the features ; the fetor of the breath ; 
sighing and faintness on assuming the sitting posture ; smallness 
and weakness of the pulse ; and coolness or coldness of the sur- 
face; it is necessary to administer, more or less freely, according 
to the number and gravity of these symptoms, tonics, aromatics, 
and cordials. Amongst these, the most important are cinchona, 
wine, camphor, and ether. Chomel prefers the cinchona, in the 
form of the extract, administered in an aromatic potion, to the 
amount of one or two ounces in the twenty-four hours. He also 
employs it in decoction or infusion, sweetened with lemon syrup. 
He doubts whether the sulphate of quinine is of equal efficacy as 
a tonic ; so that, notwithstanding the inconveniences frequently 



TREATMENT. — CHOMEL'S METHOD. 1T7 

attending the administration of the extract, especially in large 
quantities, he still prefers it to the former. At the same time 
that the cinchona is employed in this manner, he uses it, either 
in decoction, or in extract, in the form of enemata. 

While the adynamic phenomena already enumerated are only 
moderate in degree, and before the necessity for the free use of 
cinchona has yet appeared, the lighter wines, such as those of 
Bordeaux and Burgundy, may be given : when these phenomena 
are more strongly marked, the stronger wines, such as Madeira, 
Sherry, and Port, must be resorted to. These may be given to 
the patient in his drinks ; or, as is best in the more grave cases, 
undiluted. The quantity to be administered must depend, of 
course, upon the urgency of the symptoms calling for its use. 
A tablespoonful of one of the strong wines may be given at in- 
tervals of from one to three or four hours. The effects of these 
remedies must be carefully watched ; and if they produce febrile 
heat, and restlessness, pain in the head, or any other obvious 
local disturbance, their use must be suspended, or modified. It 
will not often be either necessary or safe to resort to them in the 
early periods of the disease ; although such will sometimes be the 
case. It is commonly during the second or third week, or even 
later, that this tonic and stimulant medication is called for ; and 
it is often a nice point, in the therapeutics of typhoid fever, to 
seize upon the exact period when it is required and will be borne. 
Ether is to be used when there is an urgent necessity for rapid 
and immediate stimulation ; Chomel also occasionally combines it 
with the mixture of the extract of cinchona. Camphor he rarely 
uses, except as an ingredient in the tonic injections. In extreme 
cases, where there is a combination of the ataxic and adynamic 
elements, he recommends the use of musk in large doses, by the 
mouth and by injection. 1 He speaks more decidedly of the evils 
attending the application of blisters, than of any benefits to be 
derived from them. 

The epistaxis will not often require any special attention. If 
it is at all copious, the application of a cold astringent solution 
will generally be suflicient to arrest it. Sometimes, however, it 
is necessary to resort to mechanical compression, by plugging up 
the nostrils. To control the hemorrhage from the bowels, Cho- 



1 Gazette Medicale de Faris, March, 1835. 



12 



178 TYPHOID FEVER. 

mel recommends iced water for drink in injections, and applied 
upon the abdomen ; lemonade, and the extract of rhatany. The 
formation of ulcers should be guarded against, by avoiding con- 
stant pressure upon those points where they are most liable to 
occur; and when once formed, they should be protected from 
irritation, and properly dressed. Local inflammations, occurring 
in the early periods of the disease, or when the debility and pros- 
tration are not strongly marked, are to be met by local and gene- 
ral bleeding, adapted to the circumstances of the case. If the 
patient is in a condition , not likely to tolerate these measures, 
dry cupping and sinapisms in the neighborhood of the inflamma- 
tion, which is most commonly a pneumonia, may be substituted. 
When these complications take place during the adynamic period, 
or in the adynamic form of the disease, they do not contraindicate 
the use of stimulants and tonics. The local inflammation under 
these circumstances will be more surely relieved, or enabled to 
relieve itself, by a removal of the extreme general debility, through 
the agency of a tonic medication, than by the abstraction of blood. 
Perforation of the intestine is to be treated after the manner of 
Drs. Graves and Stokes of Dublin; by entire abstinence from 
drinks and food ; absolute rest; and large and repeated doses of 
opium. In the management of the patient during convalescence, 
Chomel urges the importance of a mild diet and the avoidance of 
fatigue ; and in cases where there seems to be some obstacle to the 
entire re-establishment of health, he recommends a removal from 
the city to the country. 

In 1831, at the suggestion of a young physician who attended 
his clinical lectures at the Hotel Dieu, Chomel commenced the 
trial of chloride of soda in the treatment of typhoid fever. He 
did not change in any other respect his system of management, 
but superadded the use of this remedy to the rational plan of 
treatment which has just been described. He administered the 
chloride in a sweetened solution of gum Arabic, containing from 
one grain to one grain and a half to the ounce. Of this solution, 
his patients generally took from fifty to ninety ounces in the twenty- 
four hours. Injections of the same solution were given morning 
and night ; the body of the patient was freely washed, several 
times a day, with a solution of the chloride in water ; poultices 
moistened with it were applied to the abdomen ; the bedclothing 
was sprinkled with it ; and vessels containing it were placed 



TREATMENT. — LOUIS'S METHOD. 179 

under the bed. In order to test as nearly as possible the value 
of this specific medication, it was mostly confined to well-defined 
cases, at least of sufficient severity to be attended with some dan- 
ger ; and in which it could be applied at the beginning or early 
in the disease. The results of this plan in the hands of Chomel, 
from 1831 to 1834, the year in which his work on typhoid fever 
was published, were various and not very decisive. In that work, 
however, he expresses himself, at the close of his remarks upon 
this subject, in the following terms: " Finally, although the re- 
sults of this treatment have been very different in different years, 
it has still been attended with more success than any other. Se- 
veral distinguished practitioners have informed us that they have 
arrived at the same conclusion. We shall continue, then, our 
trials with a mode of treatment which, combined with the rational 
method, has thus far given us, notwithstanding its failures, more 
satisfactory results than any other." Subsequent to this, how- 
ever, in 1835, with a frankness, a conscientiousness, a single- 
minded regard for the truth which it is beautiful to witness, he 
says: " The hopes which our first trials with the chloride had 
permitted us to conceive have not been realized. The results 
which have thus far been obtained are not sufficiently encourag- 
ing to justify us in the expectation of continuing our trials with 
much chance of success." 1 



ARTICLE IV. 

LOUIS'S METHOD. 

Louis, in the second edition of his Researches on Typhoid 
Fever, published in 1841, seems somewhat undecided in his 
opinion upon the therapeutics of the disease. 2 He hesitates be- 
tween the rational method which he had generally followed, and 
the purgative plan adopted by De Larroque. Putting the latter 
out of consideration for the present, Louis, after a very careful 
and thorough examination and analysis of the effects of remedies, 
finally fixed upon the following general plan of treatment, as the 
best that could be pursued in the present state of our knowledge 
upon this subject. 

1 La Lancette Francaise. August, 1835. 

2 Louis on Typhoid Fever, vol. ii. p. 379, ci sea., 2d ed. 



180 TYPHOID FEVER. 

Early in the disease, and at any rate within the first ten or 
twelve days, he resorts to general bloodletting, its extent and 
repetition to be proportionate to the strength and vigor of the 
patient and the severity of the disease. If the case is mild, or of 
moderate severity, and the constitution of the patient not very 
robust, a single bleeding of twelve ounces will be sufficient ; in 
other cases of greater severity, and where the constitution is sound 
and vigorous, the bleeding should be somewhat more copious, and 
repeated once or twice. Louis is satisfied that this remedy, 
within these limits, is generally useful in shortening to the extent 
of a few days the average duration ; in diminishing the gravity, 
and of course in lessening somewhat the mortality, of the disease. 
After the fifteenth day, in severe cases, and at an earlier period 
in mild ones, where there is but moderate febrile excitement, 
bloodletting should not be practised. Under these circumstances, 
the operation does no good, and retards instead of hastening the 
period of convalescence. Louis has not found the immediate 
effects of bloodletting, either upon the general severity of the dis- 
ease or upon any of the single symptoms, to be very marked or 
obvious. In some cases, the operation is followed, either at once 
or in the course of twenty-four hours, by an amelioration of one 
or more of the most urgent symptoms : in some cases, on the other 
hand, it is followed by their aggravation ; and furthermore, these 
changes in the severity of the symptoms are such as frequently 
occur where blood-letting has not been resorted to, and where, 
indeed, no active medication has been used. 

This measure is to be aided by suitable drinks, emollient ene- 
mata, and cool fresh air. The drinks should consist of sweetened 
gum water, or of this in combination with artificial Seltzer water, 
in order to obtain the effects of the carbonic acid gas. They 
should be given in large quantities, as freely as the patient may 
desire. Mucilaginous enemata are to be given once a day, during 
the early period of the disease ; and subsequently when the diar- 
rhoea is troublesome, two or three times a day. If, notwith- 
standing their use, the discharges from the bowels continue to be 
frequent and debilitating, a small injection containing a few drops 
of laudanum should be substituted. 

Tonics are considered by Louis not only very useful, but very 
necessary, under certain circumstances. When the general febrile 
excitement has subsided; when the prostration of strength is 



TREATMENT. — LOUIS'S METHOD. 181 

extreme; when the pulse is only moderately accelerated, or not 
at all ; when there is slight diarrhoea, and little or no tympanites ; 
they should be at once and freely resorted to. Louis prefers the 
sulphate of quinine to any other article, given in an aromatic or 
mucilaginous draught, in doses of from eight to twenty grains. 
He gives the patient at the same time a sweetened infusion of 
cinchona for drink ; and if there is diarrhoea, he makes use of 
tonic and astringent injections. 

Louis dismisses blisters from his plan of treatment with strong 
and unqualified condemnation. He says there is no evidence 
that they are of any benefit, and that not unfrequently they add 
to the gravity, the inconveniences, and danger of the disease. 
For the last ten or twelve years he has abandoned them entirely. 
He recommends opium, after the method of Graves and Stokes, 
in cases of perforation of the intestine, though in smaller doses. 
He reports a case, probably of this accident, which occurred at 
the Hotel Dieu in 1840, and which was cured by this method. 
Opium, he thinks, is also of use in allaying some of the nervous 
symptoms; such as twitching of the tendons and slight delirium, 
when the febrile excitement is not very high. When the delirium 
is violent, he has seen little or no benefit from the use of leeches, 
or the application of ice to the head ; but he recommends, in this 
case, if the face is flushed, even if the disease has reached its 
twelfth or fifteenth day, and even if the patient has already been 
twice bled, another moderate bleeding. When the meteorism is 
extreme, he thinks it may sometimes be diminished by the admi- 
nistration of enemata, consisting of magnesia in an infusion of 
flaxseed. In grave cases, the condition of the bladder should be 
carefully watched from day to day, and retention of urine guarded 
against. It is unnecessary to repeat his observations upon the 
importance of rest, cleanliness, and free ventilation, during the 
progress of the disease ; and of light diet and the avoidance of 
fatigue during convalescence. 

In concluding this subject, Louis makes use of the following 
words : " It results from all that precedes, upon the effects of the 
principal therapeutic agents at present employed in the treatment 
of typhoid fever, that these agents possess a favorable though 
limited influence upon the march and termination of the disease ; 
and that an impartial examination of facts points out, with a good 
degree of precision, the best method of employing the three 



182 TYPHOID FEVER. 

principal means which experience has placed in our hands ; to wit, 
bloodletting, evacuants, and tonics. Furthermore, the limited 
degree of success which has thus far been obtained ought not 
to discourage the friends of science, nor prevent them from hoping 
that a more appropriate and successful treatment of this disease 
will yet be discovered. Who could have foreseen the effects of 
opium, of cinchona, or the preservative power of the vaccine 
virus ? What accident and observation have hitherto done they 
are still able to do, without doubt they still will do ; and thera- 
peutics, like the other parts of science, ought to hope and to 
expect everything from observation." 

ARTICLE V. 

bouillaud's method. 

Some twenty-five years ago, Bouillaud introduced a mode of 
practice in the treatment of all acute diseases, and amongst them 
of typhoid fever, which he claims to be of his own discovery, 
and which he claims also to have been attended with extraordi- 
nary success. This mode consists in copious and frequently re- 
peated abstractions of blood, and in the application of leeches or 
of scarified cups in the intervals. 1 The number of his bleedings 
varies from one to five or six, of from twelve to sixteen ounces 
each ; and nearly or quite an equal quantity of blood is taken from 
the patient by means of leeches or cups. This lavish waste of 
the vital fluid is not confined to the earliest period of the disease, 
since many of the patients who are subjected to it are not re- 
ceived into the hospital until the second week of the fever. The 
average day, indeed, is as late as from the ninth to the twelfth. 
This method he calls that of bleeding coup sur coup, blow upon 
blow, or dash upon dash, or again and again. He claims to have 
reduced the practice of bloodletting in acute diseases to an esta- 
blished formula. In connection with this subject, he also an- 
nounces, in loud and confident tones, that success or cure is the 
law ; failure or death the exception. He claims for his new 
method an almost infinite degree of superiority over those generally 

1 Essai sur la Philosophie Medicale, etc. Par J. Bouillaud, p. 412, et seq. 
Bruxelles, 1836. 



TREATMENT. — DE LARROQUE'S METHOD. 183 

in use; and that the actual average mortality, under it, is less 
than half as great as under the old and generally adopted plans. 
The bold and arrogant terms in which these high pretensions 
were put forth, the offensive freedom of Bouillaud's remarks upon 
the practice of his contemporaries, to say nothing of the import- 
ance of the subject, and the interests of humanity and science, 
soon led to a thorough examination and a discussion, generally 
warm and sometimes intemperate, of his claims. It is not my 
intention to enter into a history of these proceedings. It is quite 
sufficient for my purpose to say that his statistical tables were 
rectified, his mistaken diagnoses were corrected, and the positive- 
results of his practice shown to be in no degree more favorable 
than those of other physicians; probably less so. It ought to be 
said, however, before dismissing the subject, that if Bouillaud has 
failed to establish the superiority of free and repeated bleeding in 
the treatment of typhoid fever, he seems at least to have shown 
that the practice is borne in this disease with a greater degree of 
impunity, and is attended with less danger, than had generally 
been supposed possible. 



ARTICLE VI. 

DE LARROQUE'S METHOD. 

There is still another exclusive mode of treatment, very unlike 
that of Bouillaud, which has been pretty extensively followed 
within the last ten or twelve years in the hospitals of Paris. I mean 
that by evacuants, and principally by purgatives. The fifteen or 
twenty years' reign of the Broussaisian doctrine of fevers, in Paris, 
had almost entirely banished emetics and purgatives from the 
treatment of these diseases. Their use was formally and abso- 
lutely proscribed. It was murderous and incendiary to give 
either one or the other. After this medico-doctrinal dynasty had 
had its day and gone by, therapeutics became gradually more 
eclectic and less exclusive. Different modes of practice were 
adopted by different physicians in the same disease; and it could 
hardly fail to be discovered that the fears which had so univer- 
sally prevailed, founded upon theoretical considerations, of the 
injurious effects of purgatives, were either without foundation or 



184 TYPHOID FEVER. 

very much exaggerated. Lerminier of Paris, and Bretonneau of 
Tours, had occasionally made use of purgatives in the treatment 
of typhoid fever ; but M. De Larroque, a physician of the Necker 
Hospital, was the first to adopt the evacuant or emetico-cathartic 
plan as a general and almost exclusive mode of treatment, in this 
disease. He commenced his trial of this method in 1831, since 
which time it has been more or less extensively followed by Pie- 
dagnel at the Hotel Dieu, Andral at La Charite', Louis at La 
Pitie', and by others. The plan adopted by De Larroque is the 
following : He usually commences his treatment by the adminis- 
tration of an active antimonial emetic ; and this is to be repeated 
until free vomiting is procured. The operation of the emetic is 
to be immediately followed by the use of purgatives, without much 
regard to the state of the bowels, the condition of the patient, or the 
period of the disease ; and these are to be continued regularly up 
to the time of convalescence. His principal articles are Seidlitz 
water, castor oil, and calomel. To these remedies, he adds emol- 
lient poultices to the abdomen, when there is pain in this region ; 
mucilaginous injections, morning and night; acidulated drinks; 
and, when the febrile excitement subsides, light tonics. Louis, in 
the second edition of his Researches, expresses himself pretty 
strongly in favor of the purgative treatment. He himself made 
use mostly of Seidlitz water, and he thinks that his success with 
this method was greater than with his former practice. 

Barthez and Billiet are opposed to the purgative plan of treat- 
ment in children ; they think it increases the danger of enteritis. 

ARTICLE VII. 

MISCELLANEOUS. 

In addition to the accounts which have been given of the fore- 
going systematic methods of treatment, it may be well to mention 
in conclusion some few individual remedies, and their applica- 
tion, which have been recommended by different practitioners. 
M. Barthez and M. Fouquier amongst the French, and Drs. Dob- 
ler and Skoda amongst the Germans, have made use of alum ; 
supposing that it might act directly in retarding the progress and 
in diminishing the severity of the intestinal lesion. I am not 



TREATMENT. — MISCELLANEOUS. 185 

aware that there is yet any satisfactory proof of its utility. Dr. 
Gerhard thinks that, in mild cases, gentle purgatives, such as a 
few grains of blue pill, followed by castor oil or Seidlitz powder, 
should always be given at first, for two or three days ; and that 
whenever constipation is present, the repetition of the laxative is 
useful. If the dizziness and headache are troublesome, he says 
that they may be removed, or greatly relieved, by cupping, by a 
mustard pediluvium, or by a blister to the nucha. From the latter 
application, when properly timed, that is, after the active febrile 
excitement has subsided, Dr. Gerhard has never known any injury 
to result, and he has generally found it to mitigate the severity of 
moderate cerebral symptoms. In both severe and mild cases, 
towards the decline of the disease — that is, about the end of the 
second week if it be severe, and a little earlier if it be mild — he 
makes use of small doses of calomel, or of blue pill, combined 
with ipecacuanha, and with a minute quantity of opium, if the 
diarrhoea is troublesome. One or two discharges from the bowels 
daily, he thinks, are of service in all stages of the disease. 1 In 
cases of hemorrhage from the bowels, I always make free use of 
opium and sugar of lead, and generally with entire success. 

I have already spoken of the unsettled and discordant state of 
the professional mind in regard to the therapeutics of typhoid 
fever. It would be no difficult matter to multiply and strengthen 
the proofs of this truth, already sufficiently shown by the fore- 
going details. This, however, would be but an unprofitable labor, 
in the present state of our knowledge of no practical value. Under 
the circumstances in which we are placed, amidst the claims and 
pretensions of conflicting opinions, it seems to me that we are 
not now justified in the use of any ultra or exclusive system of 
treatment; like that, for instance, of Bouillaud, or De Larroque. 
For the present, our management of the disease must be eclectic 
and rational, not exclusive and specific. In its early stages, 
unless in cases where there may be special contraindications, it 
seems to be generally conceded that a moderate antiphlogistic 
course is the best that can be adopted ; and that active emetico- 
cathartics, if used at all, ought to be used at this same early 
period. In the subsequent progress of the disease, a mild altera- 

1 Medical Examiner, vol. iy. pp. 150, 151. 



186 TYPHOID FEVER. 

tive and rational plan, keeping the bowels moderately loose by 
laxatives when this is necessary, and meeting particular symp- 
toms with such remedies as experience has shown to be most 
suitable, would appear to be most appropriate and successful. 
After the first few days, in cases of moderate or average severity, 
with no special or urgent indication, it is quite clear, I think, that 
all treatment in any way decidedly active or perturbating is to 
be avoided. The tendency of the disease in all such cases is 
towards a natural termination in health ; and there is no evidence 
that the dangerous complications which are liable to occur can 
be prevented by any active interference. In all grave cases, and 
especially when stupor or delirium is present, the region of the 
bladder should be carefully examined every day, in order to 
guard against the distension of the organ by urine. I may re- 
mark in this connection, notwithstanding what has been said, 
that carelessness or indifference in the management of the disease, 
growing out of the unsettled state of opinion in relation to its 
treatment, and of the limited control which we possess over it, 
would be as criminal a dereliction of duty as it would be unbe- 
coming in a cultivator of the science and a practitioner of the 
art of medicine. 1 

We may hope that our treatment of this disease will yet become 
more successful and more uniform ; more exact in its application, 
and more positive in its results. Many " ministers and inter- 
preters of nature," faithful to their high vocation, and competent 
to its duties, are zealously and patiently occupied in endeavoring 
to accomplish this end. Guided by a sound philosophy, relying 
upon the one great means of ascertaining the properties and 

1 It is both interesting and gratifying to see the good sense and sound judgment 
of some of the continental practitioners of the last century, in the management of 
this disease. Burserius, after having given a most excellent description of the 
fever, recommends moderate bleeding where there is much excitement, a mild 
emetic at the commencement, diluent drinks, and then says : "But a simple plan 
of cure, if it is to be recommended in any case, is certainly to be adopted in the 
present. For the less the operations of nature are disturbed by art, the milder 
and safer the remedies we employ are, the more successfully do we restore the 
patient's health." — Institutions Pract. Med., vol. i. p. 506. And again, he adds: 
" The proper regulation of the diet alone, and time, perform great part of the cure. 
The poorer people, generally content with patience and proper attention to the 
regulation of the diet, despising all kinds of drugs, recover more certainly." — 
Ibid., 530. 



TREATMENT. — MISCELLANEOUS. 187 

relations of all forms of matter, inorganic and organic, that of 
observation, they or their successors may yet find, by persevering 
experiment or fortunate discovery, methods of modifying the 
living organisation, and of correcting its disordered actions, which 
shall give us a much greater control over the disease than we are 
now able to exert. 



188 



CHAPTER XI. 

DEFINITION. 

We may, provisionally at least, adopt the following definition 
of the disease, the natural history of which has now been given. 

Typhoid fever is an acute affection ; occurring most frequently 
between the ages of fifteen and thirty years, sufficiently often 
previous to the former period, and but rarely after the fortieth 
year of life; attacking, at least in cities and amongst adults, in a 
large majority of instances, persons who are recent residents ; 
occasionally, and under certain conditions, capable of transmission 
from one individual to another ; rarely occurring twice in the same 
person ; more common in certain countries than in others, but 
not confined, so far as is known, to any geographical localities 
or regions ; prevailing at all seasons of the year and in all cli- 
mates, but more common in the autumn than at other periods, 
and in temperate and northern than in southern and hot latitudes ; 
sometimes sudden and sometimes gradual in its access ; attended 
at its commencement with chills or rigors, not commonly very 
severe, and usually repeated, at uncertain intervals, for the first 
few days ; then, with more or less feverish heat of the skin ; 
generally, with increased quickness of the pulse; somewhat 
accelerated respiration; slight, dry cough; an extensive sono- 
rous or sibilant rhonchus; with pain in the head, back, and 
limbs ; loss of the vigor, and in grave cases perversion of the 
faculties of the mind ; dull expression of the countenance ; more 
or less somnolence or watchfulness ; giddiness or dizziness ; ring- 
ing, roaring, or buzzing in the ears ; occasional epistaxis ; great 
loss of muscular strength ; in grave cases, with spasmodic twitch- 
ings of the muscles, especially those of the forearms and hands ; 
with entire loss of appetite, and with thirst; sometimes with 
nearly a natural appearance of the tongue, and at others with 
a red, dark, dry, glutinous, cracked, trembling state of this 
organ ; sordes upon the teeth and gums ; occasional nausea and 



DEFINITION. 189 

vomiting ; frequent diarrhoea ; abdominal pains and tenderness ; 
these latter not unfrequently most marked in the right iliac 
region ; dulness on percussion over the spleen ; meteoric dis- 
tension or rigidity of the abdomen ; the skin, particularly of the 
front part of the body, being usually the seat, in the course of 
the second and third weeks of the disease, of a peculiar eruption, 
not commonly abundant, consisting of small, circular, or oval 
spots, of a bright rose color, slightly elevated above the surround- 
ing surface, and readily disappearing under pressure; coming 
out successively one after another for several days, remaining 
usually for somewhat more than a week, and successively and 
gradually fading away and finally disappearing ; the blood, when 
drawn from the body, having its proportion of fibrine diminished 
in a degree closely corresponding to the gravity of the affection : 
which symptoms differ very widely in their duration, in their 
march, in their severity, and in their combinations, in different 
cases ; no one of which is invariably met with, and several of 
which are frequently wanting ; but enough of which are almost 
always present to characterize the disease: which symptoms, 
furthermore, may either gradually diminish in severity, and finally 
disappear, between the twelfth and the thirtieth day of the disease, 
or may increase in severity and terminate in death between the 
seventh and the fortieth day from their access : the bodies of 
patients exhibiting on examination after death, in only a certain 
proportion of cases, various pathological changes in the brain, 
heart, lungs, stomach, and liver ; but in most cases enlargement 
or softening, or both, of the spleen ; and in all cases thickening 
or redness, or a morbid deposition in the subcutaneous cellular 
tissue, or ulceration, or all these changes, of the elliptical plates 
of the ileum ; with enlargement, redness, and softening of the 
mesenteric glands, corresponding in their position to the altered 
intestinal follicles : which disease, thus characterized and defined, 
differs essentially from all others, in its causes, in its symptoms, 
in its lesions ; and is, in the present state of our knowledge, only 
to a limited extent under the influence or control of art. 



190 



CHAPTER XII. 

BIBLIOGRAPHY. 

The bibliography of typhoid fever, as a distinct and specific 
disease, may properly enough be said to have commenced with 
the publication of Louis's Researches, in 1829. I do not forget 
the earlier works of Roederer and Wagler, in Germany ; and of 
Prost, Petit and Serres, and Bretonneau, in France, on the same 
subject; nor the description of Huxham in England, and of Na- 
than Smith in America : but these publications, compared with 
that of Louis, were fragmentary and incomplete. Other conti- 
nental writers have also given very good general descriptions of 
the disease, under the names of typhus, adynamic, ataxic fever, 
and so on. These descriptions are now of but little value, for • 
the reason that no clear distinction was made between true typhus 
and typhoid fever. It indeed remains to the present moment a 
question undecided, whether the camp, the jail, and the typhus 
fevers of the continent of Europe, previous to the thorough study 
of typhoid fever, were identical with this disease, or constituted 
a distinct and different species. My own opinion is, as I have 
already stated, that both parties are partly right and partly 
wrong. It is probable that both typhoid and true typhus fever 
made up these diseases ; and it is quite impossible to determine 
now, in many cases, to which of the two any particular epidemic 
belonged. 

Besides the few but very important works which are hereafter 
briefly mentioned, Andral, Bouillaud, Cruveilhier, and others 
amongst the French ; and Schonlein, Skoda, Rokitansky, and 
others amongst the Germans, have written more or less exten- 
sively and systematically upon this disease. Several important 
papers have also been published in the French medical journals. 

MSdecine eclairee par V observation et Vouverture des corps. 
Par P. A. Prost. Paris, 1804. In connection with the history 
of the researches in relation to typhoid fever, this is a very re- 



BIBLIOGRAPHY. — PROST. 191 

markable book. Prost may be fairly regarded as one of the far 
forerunners of Louis. He seems to have devoted himself for a 
considerable period of time with great assiduity and faithfulness, 
and almost exclusively to the observation of disease, in its most 
extended sense, in the large hospitals of Paris. Before publish- 
ing his book, he had made more than four hundred autoj> 
many of them requiring an entire day, and none less than several 
hours. One of the first fruits of his arduous and conscientious 
study of nature was the discovery that, in the ataxic fevers of 
Paris, there always existed inflammation, with or without ulcera- 
tion, of the mucous membrane of the intestines. Bouillaud, in 
speaking of Prost's work, says: "This fine commencement of a 
revolution, which ten years later was destined to shake the 
temple of medicine to its deepest foundations, was suffered to 
pass almost unnoticed. Truly, Prost might have said of his 
epoch, as Tacitus said of another : ' Nostra oetas oblivia suo- 
rum.' " 

There is a curious fact in medical literature, connected with 
this portion of the history of fever. Prost's book, as Grisolle says, 
fell stillborn from the press. Almost the only one of his con- 
temporaries who took any special notice of it was Broussais ; — 
and a singular notice this was, coming as it did from a man whose 
highest title to glory — subsequently claimed for him, both by his 
disciples and by himself — consisted in a fuller development of this 
very doctrine of Prost. Broussais, in the first edition of his His- 
tory of Chronic Inflammations, after citing the opinion of Prost, 
relative to the influence of inflammation of the digestive mucous 
membrane in the production of ataxic fever, says : i; I have too 
often found this membrane in good condition after the most malig- 
nant typhus ; I have seen too many patients improved bj the 
employment of the most energetic stimulants, to share the opinion 
of this physician on the cause of ataxic fever." And still, the 
truculent and unscrupulous reformer, after having thus summarily 
rejected, as worthless, the materials which had been laboriously 
quarried from the great primary formation of nature, did not 
hesitate to make use of them as corner-stones for the temple 
which he himself strove to build. 

Prost's work is in two volumes, and the greater part of it is 
made up of short histories of disease, with an account of the 
several organs after death ; — only a small proportion of these 



192 TYPHOID FEVER. 

being cases of fever. The preliminary observations are to a great 
extent speculative and hypothetical. 

A Practical Essay on Typhous Fever. By Nathan Smith, 
M. D. The author of this modest and unpretending essay was 
an extensive and distinguished teacher and practitioner of medi- 
cine and surgery throughout many portions of the New England 
States during the first quarter of the present century. He was 
a remarkable man ; and his name stands worthily and fitly by the 
side of those of Huxham, Pringle, and Blane. My opinion of the 
value of the essay above mentioned has been already sufficiently 
attested, by the incorporation into my book of a large portion of 
its matter. To an American practitioner, it is worth infinitely 
more than all the modern English treatises on fever put together ; 
for this simple reason, if for no other, that it deals with the form 
of disease with which he is familiar — which the English treatises 
do not do. Nathan Smith was a shrewd, clear-headed, patient, 
and careful student of nature — his vision undazzled and his judg- 
ment never perverted by fanciful speculations; and the labor of 
my book will not be wholly lost if it succeeds in some degree in 
calling back the attention of my countrymen to his neglected and 
almost forgotten pages. The essay was published in 1824. 

Anatomical, Pathological, and Therapeutical Researches upon 
the disease known under the names of Gf-astro-Enteritis ; Putrid, 
Adynamic, Ataxic, and Typhoid Fever. By P. Oh. A. Louis, 
2 vols. Paris, 1829. This is the great work of Louis, to which 
reference has been so constantly made throughout the preceding 
history. An American edition was published from a translation 
by Henry J. Bowditch, M. D., in 1836. A second French edi- 
tion was published in 1841. The work at the time of its first 
appearance was entirely without a parallel, if we except the Re- 
searches on Phthisis, by the same writer. These works of Louis 
have become the established models for all similar undertakings ; 
they are the standards by which all analogous labors are to be 
tried. Here and there, a single individual has attempted to 
depreciate their value and underrate their importance — a value 
and an importance which every successive year since their appear- 
ance has only served to strengthen and confirm. Like new planets 
added to a solar system, they have quietly but irresistibly wheeled 
into their orbits, from which they are henceforth no more to be 
jostled than the planets are from theirs. 



BIBLIOGRAPHY. 193 

Lecons de Clinique 3Iedicale, etc. Par A. F. CJiomel. Fievre 
Typhoide. Paris, 1834, pp. 548. Next to the great -work of 
Louis, this is perhaps the most valuahle original treatise on 
typhoid fever that has been published. It is not so methodical in 
its plan and arrangement as it might have been, and the anato- 
mical details are somewhat prolix, extending as they do to nearly 
two hundred and fifty pages ; still, as I have just said, the work is 
second only to one in value. It is rich in solid material, and is 
marked throughout by the clearness, good sense, and sound phi- 
losophy of its distinguished author. 

A Report, founded on the Cases of Typhoid Fever, or the com- 
mon Continued Fever of New England, which occurred in the 
Massachusetts General Hospital, from the opening of that Institu- 
tion in September, 1821, to the end of 1835. By James Jackson, 
M. D., pp. 93, 1838. There is no need of my speaking at any 
length of this Report; the preceding pages bear ample and con- 
clusive evidence of the richness and value of its materials. It 
consists mostly of a careful and accurate numerical analysis of 
three hundred and three cases of typhoid fever treated in the 
Massachusetts General Hospital. It is altogether the most im- 
portant contribution which has been made to the history of the 
continued fever of New England, and it is in every way worthy 
its distinguished author, the elder Louis of the New World. 

Remarks on the Pathology of the Typhoid Fever of Neiv Eng- 
land; as exhibited in its Physical Signs and its Anatomical Ap- 
pearances. By Enoch Hale, 31. D., 1839, pp. 68. This paper, 
like the Report of Dr. Jackson, is published amongst the Com- 
munications of the Massachusetts Medical Society. It is a very 
excellent and sensible paper ; and it is particularly valuable for 
its minute and careful description of some of the more charac- 
teristic physical signs of typhoid fever — such as the meteorism, 
and the rose spots ; and of the intestinal lesions ; and further, 
for its full and clear statement of the differences between typhoid 
and typhus fever. 

Traite de VEnterite Folliculeuse — Fievre Typhoide. Par C. 
P. Forget. Paris, 1841, pp. 846. This is a work of very large 
promise,' and of very moderate performance. It is a full and 
systematic monograph of more than eight hundred solid pages, in 
which the author has contrived neither to give us a compact and 
clear summary of the researches of others, nor to add any import- 
13 



194 TYPHOID FEVER. 

ant knowledge of his own. As Sir James Mackintosh said on 
another occasion, it is one of the most unnecessary books in the 
world. One of its leading objects is to vindicate the strictly local 
and inflammatory nature of typhoid fever, and the consequent 
rational antiphlogistic treatment. 

On the Identity or Non-identity of Typhoid and Typhus 
Fevers. By William Jenner, M. D., London, 1850, pp. 102. 

On the Identity or Non-identity of the Specific Cause of Ty- 
phoid, Typhus, and Relapsing Fever. By William Jenner, 
M. B., London, 1850, pp. 20. 

Typhus Fever, Typhoid Fever, Relapsing Fever, and Febri- 
cula ; the diseases commonly confounded under the term Con- 
tinued Fever. Illustrated by Cases collected at the bedside. By 
William Jenner, M. B., London Medical Times, 1850. 

I have already alluded to these publications, and expressed nry 
opinion of their value. It is not necessary that I should give 
any detailed account or analysis of them here. The more im- 
portant portions of their contents are introduced into the present 
edition. Dr. Jenner is Professor of Pathological Anatomy in 
University College, London ; his observations were made in the 
London Fever Hospital; and that these observations were ex- 
tensive, thorough, careful, conscientious, and complete, no one 
who reads the record of them will for a moment doubt. 



PART SECOND. 



THE 



HISTORY, DIAGNOSIS, AND TREATMENT 



OF 



TYPHUS FEVER 



PART II. 
TYPHUS FEYEE 



CHAPTER I. 

PRELIMINARY MATTERS. 

ARTICLE I. 

INTRODUCTORY. 

I now proceed to the description of Typhus Fever. The na- 
tural history which I shall be able to give of this disease will be 
somewhat less complete than that which I have already given of 
typhoid fever. The reason of this is twofold : in the first place, 
I have seen much less of the disease myself; and in the second 
place, but few entire and elaborate histories of the disease have 
been published. We have many excellent general descriptions 
of it, especially as it has shown itself in certain localities, and 
during certain epidemic periods; but we have had no thorough 
and detailed histories of its symptomatology and lesions ; like 
those which Louis, Chomel, and others have furnished us of 
typhoid fever. To these remarks it may be added that the 
diagnosis of typhus fever, by most of the observers upon whose 
records we must depend for our materials, is much less accurate 
and positive than that of typhoid fever is, as this disease shows 
itself in New England, and in France. Typhus fever is more 
frequently confounded and mixed up tvith other diseases, by its 
best historians, than typhoid fever is ; and in this way, another 
element of incompleteness and confusion is introduced into its 
history. The foregoing remarks, contained in my second edition, 
need some qualification in consequence of the recent appearance 
of the papers of Dr. Jenner. 



198 TYPHUS FEVER. 

The materials for the following description will be derived 
mostly from British physicians, and from Dr. Gerhard of Phila- 
delphia. The accounts of typhus fever which have been pub- 
lished from time to time, and mostly in the .form of Hospital Re- 
ports, by the Scotch and Irish practitioners, constitute our richest 
and most authentic sources of information in the study of this 
disease. This remark is especially applicable to the Hospital 
Reports of Dublin, made subsequent to the year 1812 ; by 
Edward Percival, John O'Brien, F. Baker, William Pickles, John 
Cheyne, and others. I know nothing of a like character in the 
English language superior to the Hospital Reports of John 
Cheyne ; and one of the most valuable histories of the disease 
now under consideration which has ever been published, is to be 
found in the account given by Dr. Barker, and Dr. Cheyne, of 
the great epidemic of typhus fever, which overran Ireland dur- 
ing the years 1817, 1818, and 1819. One reason for this re- 
liance, which I am disposed to place upon the observations of 
Irish and Scotch writers, rests upon the belief, the grounds of 
which will be fully stated hereafter, that true typhus fever is 
more exclusively the prevailing fever in Ireland, and in the north- 
ern portions of the British empire, than it is in the middle and 
southern regions of England. Dr. Gerhard has published, in 
the American Journal of Medical Sciences, a very valuable his- 
tory of an epidemic typhus fever which prevailed in Philadelphia, 
during the spring and summer of 1836, and which was carefully 
studied by himself and Dr. Pennock. I am aware of the danger 
of trusting to the phenomena presented by any single epidemic 
in making up the history of a disease, and I do not intend in the 
present instance to be guilty of this fault. I look upon tjie pa- 
pers published by Dr. Gerhard, as of inestimable value ; but it 
is only by a careful examination of many histories of typhus 
fever, and by a methodical arrangement of the materials which 
they may furnish, that I can hope to make out even a tolerably 
complete and satisfactory description of the disease. 

I shall follow, as far as this can conveniently be done, the 
same general plan, in the disposition of the several subjects of 
inquiry and description, as has already been adopted in the fore- 
going history of typhoid fever. 



PRELIMINARY MATTERS. 199 

ARTICLE II. 

NAMES OF THE DISEASE. 

The term typhus, from the loose manner in which it has heen 
used, and the various morbid conditions to which it has heen ap- 
plied, has become somewhat indefinite in its signification. It is 
only important for me to say here, that I mean by it an idiopa- 
thic, contagious fever, prevailing generally amongst crowded 
populations, and in badly ventilated localities, and not marked 
by any constant lesion of the solids. The other most common 
names by which it has been known are the following, to wit : 
Hospital Fever; Jail Fever ; Camp Fever ; Malignant Fever; 
Putrid Fever; Petechial Fever; and Contagious Typhus. It 
should be added that these latter terms have not been invariably 
and exclusively confined to true typhus; they have been some- 
times applied to typhoid fever. 



200 



CHAPTER II. 

SYMPTOMS. 

ARTICLE I. 

MODE OF ACCESS. 

Typhus fever is sometimes sudden and sometimes gradual in 
its access. I am unable to state, with any degree of certainty, 
the proportion between these classes of cases. In six of 
eight cases, reported by Dr. Gerhard, the patients complained, 
for a period of from three to seven or eight days, of various 
uncomfortable feelings ; such as languor, loss of appetite, sore- 
ness of the muscles, sleeplessness, wandering pains in different 
parts of the body, and so on. In the other two cases, the disease 
came on suddenly. Dr. O'Brien says that these premonitory 
symptoms continue generally for a few days, but sometimes for 
a week or two. Amongst these symptoms, he enumerates lassi- 
tude and fatigue on the least exertion ; dulness of the eyes ; 
sallowness, and dejected expression of the face; heavy, dull pain 
in the head ; slight nausea ; anxiety, without any apparent cause ; 
slight chills, frequently repeated, especially towards night, and 
imperfect disturbed sleep. 1 Dr. Pickels speaks of the disease as 
being nearly always preceded by trembling and nausea. 2 Dr. 
John Cheyne, in his description of the fever of the spring and 
summer of 1818, as it showed itself at the Hardwicke Hospital, 
Dublin, says: "Some patients felt an unaccountable dejection of 
spirits, for several days before seizure ; some continued at work 
or labor for several days after their illness began in the shape of 
a headache, which frequently intermitted ; in a few, the disease 

1 Trans, of Phys. of Ireland, vol. i. p. 410. 2 Ibid., vol. iii. p. 196. 



SYMPTOMS. — CHILLS. 201 

began with intense headache without rigor ; the patients being, 
as they said, at once knocked down." 1 

Dr. Jenner says: " Of sixteen of forty-three fatal cases, no 
particulars as to whether the disease began suddenly or insidi- 
ously could be obtained. Of the remaining twenty-seven cases, 
twenty-three were taken ill suddenly ; nineteen of these twenty- 
three cases first kept their beds as follows : — 

Four on the first, six on the second, five on the third, three 
on the fourth, and one on the sixth clay. 

Thus, all these patients were confined to their beds before the 
seventh day. Of these twenty-three cases, when four took to 
their bed was not learned. In four of the twenty-seven cases of 
which a correct history was obtained from the patients or their 
friends, the disease began insidiously, so that the day of its com- 
mencement could not be exactly ascertained, but they took to 
their beds on about the second, third, fourth, and sixth days; so 
that, if this group be added to the first, every patient may be 
said to have been confined to bed by the sixth day. 2 

Many writers, who have seen much of the disease, mention 
cases in which persons in full health, while standing by the bed 
of the sick and breathing the infected atmosphere from the body 
and bed of the patient, have been instantaneously seized with 
nausea, giddiness, faintness, and so on, and these symptoms have 
been immediately followed by the gravest form of the fever. 
These sudden seizures are more common in typhus than they 
are in typhoid fever ; indeed, I do not know that they are ever 
seen in the latter disease. 



ARTICLE II. 

FEBRILE SYMPTOMS. 

Sec. I. — Chills. I do not know that there is anything pecu- 
liar, or characteristic, in the initiatory chill of typhus. Many 
writers speak of it very indefinitely, or not at all. Sometimes 
it is of some severity, and well marked ; but in many cases it 
seems to consist merely of a sense of chilliness felt over the whole 

' Dub. Hosp. Rep., vol. ii. p. 4. 

2 Dr. Jenner on Typhoid and Typhus Fever, p. 8. 



202 TYPHUS FEVER. 

body, or especially perhaps along the back, and continuing not 
unfrequently for two or three days. 

Sec. II. — Heat and State of the Shin. After the disease is 
fully formed, the surface of the body becomes preternaturally 
hot. The heat of the skin is peculiar and pungent, constituting 
what has been called " color mordicans." Dr. Gerhard says, 
that this burning heat of the skin was so remarkable, in the 
Philadelphia epidemic of 1836, that the resident physicians and 
others could frequently diagnosticate the disease from this symp- 
tom alone. This morbid heat is generally accompanied by dry- 
ness of the skin. It is increased towards night, formings a well- 
marked evening exacerbation. Dr. Edward Percival observes 
that the strongly marked exacerbation occurs more frequently in 
the first than in the second or third week of fever. During 
the spring and summer of 1817, the temperature of the surface, 
on the day of admission to the Hardwicke Fever Hospital, Dub- 
lin, was ascertained by the thermometer in two hundred and fifty 
cases. It ranged from 96 to 100 deg. Fah. inclusive, in eighty- 
three cases; from 101 to 106 deg. Fah. inclusive, in one hundred 
and sixty-three cases ; and from 107 to 109 deg. Fah. inclusive, 
in four cases. 1 During the winter and spring of 1818, a similar 
examination was made of ninety-nine cases, with similar results. 
The temperature ranged from 95 to 100 deg. Fah. inclusive, in 
twelve cases ; and from 101 to 106 deg. Fah. inclusive, in seventy 
cases ; and from 107 to 109 deg. Fah., in seventeen cases. To- 
wards the termination of the disease, the skin not only loses this 
acrid and burning heat, but frequently becomes cooler than na- 
tural. Sir Gilbert Blane, in his excellent description of typhus, 
studied mostly on shipboard, says : " The symptom next to be 
taken notice of, though a minute one, is very constant and 
characteristic in this sort of fever. It is a peculiar heat in the 
skin, communicated to the hand of another person. It is usual 
to grasp the wrist of the patient after feeling his pulse, in order 
to examine the state of the skin in point of heat and moisture ; 
and in doing this a glow of heat is impressed on the palm of the 
hand, which lasts for some hours, if one should neglect so long 
to wash the hands." 2 In connection with the same subject, a still 

1 Dub. Hos. Kep., vol. ii. p. 10. 2 Obs. Dis. of Seamen, p. 355. 



SYMPTOMS. — PULSE. 203 

older and equally careful observer, Sir John Pringle, remarks : 
" In the beginning, the heat is moderate ; even in the advanced 
state, on first touching the skin, it seems inconsiderable; but upon 
feeling the pulse for some time, I have been sensible of an un- 
common ardor, leaving an unpleasant sensation on my fingers 
for a few minutes after. The first time I observed this, I re- 
ferred it to the force of imagination ; but I was assured of the 
reality by repeated experiments, and by the testimony of others, 
who, without knowing of my observation, had made the same 
remark." 1 

Most writers upon this disease speak of the odor from the body 
of the patient. Southward Smith calls it peculiar and charac- 
teristic, but does not attempt to describe it. John Cheyne men- 
tions the offensive fetor from the patient. Dr. Gerhard is more 
explicit upon this point. He says that this peculiar odor was 
pungent, ammoniacal, and offensive ; especially in severe cases, 
and in fat, plethoric individuals ; sometimes, for a few days be- 
fore death, the smell resembled that of putrid animal matter. 
The bodies of these patients ran into decomposition very rapidly 
after death, although, before putrefaction, the odor was less pun- 
gent than it was during life. Dr. Pickles says that, upon enter- 
ing the room of a patient, the presence of typhus fever was in- 
dicated, previous to any examination, by this peculiar fetor from 
the skin. 

Sec. III. — Pulse. The pulse is generally very frequent. In 
severe and fatal cases, it is often more than one hundred and 
twenty in the minute, and not unusually as high as one hundred 
and fifty. Of two hundred and thirty-seven cases, in the Hard- 
wicke Fever Hospital, the average frequency of the pulse, on the 
day of admission, was from fifty-two to seventy-eight in twenty- 
seven ; from eighty to one hundred in seventy-nine ; from one 
hundred and two to one hundred and twenty in ninety-five ; and 
from one hundred and twenty-four to one hundred and eighty in 
thirty-six. 2 The rapidity of the circulation was generally, but 
not uniformly, proportionate to the excess of temperature. 
Sometimes, though rarely, the frequency of the pulse, even in 
very grave cases, is below the natural standard. It is generally, 

1 Obs. Dis. of Army, p. 259. 

2 Dub. Hosp. Rep., vol. ii. p. 4. 



204 TYPHUS FEVER. 

but not always regular. Dr. Gerhard says that the peculiar 
undulation in the motion of the artery, so frequent in typhoid 
fever, was rarely felt in the Philadelphia typhus of 1836. . 

The pulse very rarely, if ever, exhibits the strength, hardness, 
and sharpness of inflammatory diseases. Sometimes, early in 
the fever, it may be somewhat full, but even then it is easily 
compressed; and after the first few days it is almost always 
small, soft, and feeble. 

Dr. Jenner says, in speaking of his fatal cases: "From the 
earliest period of the disease that any of the forty -three patients 
came under my observation, the pulse was decidedly soft, gradu- 
ally became weak, then very weak, and in many cases during the 
last few days of life imperceptible. Generally small, it was 
occasionally full, but still retained its extreme softness." 1 

In this connection, better than anywhere else, I may speak of 
the feeble action of the heart. This feebleness in the contraction 
of the central organ of the circulation is particularly mentioned 
by Dr. Stokes of Dublin, and other writers on typhus fever. 
Dr. Gerhard found it extreme in many cases, even from the ear- 
liest period of the disease. 

ARTICLE III. 

THORACIC SYMPTOMS. 

In most cases of typhus, there is some lesion of the respiratory 
organs, manifesting itself by signs or symptoms during life. Dr. 
Gerhard found, early in the disease, a feeble and imperfect re- 
spiratory murmur over the posterior portion of the chest, with 
corresponding dulness on percussion. These signs were frequently 
but not always combined with a subcrepitant or mucous rhonchus. 
This latter was more common during the cold than during the 
warm weather. The sibilant rhonchus, common in typhoid fever, 
was rare in this epidemic. Pneumonia constituted the most fre- 
quent accidental complication, especially in the winter. It was 
indicated by a loose mucous rhonchus, instead of the fine dry 
crepitus and bronchial respiration of simple pneumonia, and was 
unattended by pajn. 

1 Dr. Jenner on Typhoid and Typhus Fever, p. 37. 



THORACIC SYMPTOMS. 205 

Dr. Pickels says that, in the typhus fever of 1817, 1818, and 
1819, in Cork, next to the affection of the head, the most promi- 
nent and constant feature was the affection of the chest, as marked, 
during the first days, hy oppression of the precordial sighing, and 
in the course of the disease by cough. The cough was generally 
accompanied by a copious and viscid expectoration, and was 
especially urgent early in the disease during the winter months. 1 

The frequency of respiration, during the active period of the 
disease, is increased. Of one hundred and seventy-one cases 
admitted into the Hardwicke Fever Hospital, during the spring 
and summer of 1817, the average frequency of the respiration 
on the day of admission was about thirty in the minute. It 
ranged from twenty to thirty in eighty-four cases ; from thirty- 
two to forty in seventy-seven cases ; and from forty-four to sixty 
in ten cases. 2 

Of two hundred patients, treated by Dr. Henderson at the 
Edinburgh Royal Infirmary, in 1838 and 1830, there were symp- 
toms of thoracic disease in seventy-three. In a large majority 
of these cases, the symptoms were bronchitic. 3 

Of Dr. Jenner's forty-three fatal cases, there was cough, 
generally slight in amount, and accompanied by little expectora- 
tion in twenty-one. " Sonorous rale was present in seven of 
these cases; three had mucous rale more or less abundant, with- 
out sonorous ; and in nine there was during life some want of 
resonance of the most depending part of the chest, i. e., the 
portion corresponding to the most depending portion of the lung, 
the patient being in the recumbent position, and on his back ; 
this region does not, it will be observed, include the extreme 
base, the root or apex of the inferior lobe; the respiratory 
murmur at the same point was accompanied by an intensely con- 
gested condition of the corresponding pulmonary tissue, occa- 
sionally passing into absolute consolidation. Doubtless the 
same physical signs were present in many other cases, but from 
the state of the patients very many were unable to be raised in 
bed sufficiently for the posterior parts of their chest to be exa- 
mined." 4 

1 Trans, of Phys. of Ireland, vol. iii. p. 198. 

2 Dub. Hosp. Rep., vol. ii. p. 11. 

3 Edin. Med. and Surg. Journal, Oct. 1839. 

« Dr. Jenner on Typhoid and Typhus Fever, p. 37. 



206 TYPHUS FEVER. 

ARTICLE IV. 

CEREBROSPINAL, OR NERVOUS, SYMPTOMS. 

Amongst the most constant and prominent symptoms of typhus 
fever, are. those connected with the nervous apparatus. They 
obtrude themselves urgently upon our observation; they are 
striking, and strongly marked in their character ; they are many 
in number; they are present at the earliest period of the disease; 
and they accompany its various stages up to the time of conva- 
lescence. Notwithstanding all this, for the very reason, perhaps, 
that it is so, I am unable to give anything like so full and dis- 
criminating a history of this extensive and important class of 
symptoms, as I have given of the corresponding symptoms, in 
typhoid fever. The British writers upon typhus fever do not 
seem to have considered it at all necessary to speak with any 
considerable degree of particularity of these symptoms; so that 
it is impossible, in the actual state of our knowledge, to make so 
satisfactory a comparison in this respect between typhus and 
other fevers, as is desirable. 

Sec. I. — Headaehe; Pains in the Bach and Limbs. Pain in 
the head is almost always present during the early period of 
typhus fever. Dr. Gerhard does not speak of it in his general 
description, but it is mentioned in all his reported cases, eight in 
number. It is very commonly amongst the premonitory symp- 
toms of the disease ; and if not present at this time, is very sure 
to constitute one of the signs of its formal and more decided at- 
tack. Dr. Henderson found it in one hundred and fifty of one 
hundred and fifty-nine cases ; it was present on the first day, in 
ninety-two of one hundred and eight cases ; and its mean dura- 
tion was ten days. 1 Dr. Pickels says of the Cork epidemic, in 
1817, 1818, and 1819 : " The most distressing source of uneasi- 
ness was the headache ; the patient, when questioned, complain- 
ing, in almost every instance, particularly of this pain, and often 
using some comparison illustrative of its acuteness. It was com- 
monly referred to the forehead, more particularly over the eyes ; 
rarely to the occiput. In a few instances it was dull and verti- 

1 Edin. Med. and Surg. Journ., vol. lii. p. 432. 
/ 



SYMPTOMS. — STATE OF THE MIND. 207 

ginous." Dr. Stewart informs us that, of one hundred and thirty- 
nine cases occurring at Glasgow, the headache was present after 
the fifth day in ninety-eight; that in between one-sixth and one- 
seventh of this number it ceased before the tenth day ; but that 
in the remaining five-sixths it continued throughout the advanced 
stages of the disease, and in eleven throughout the whole course 
of the affection. 1 The headache is usually accompanied by pains, 
more or less constant and severe, in the back, and in the extre- 
mities, particularly the legs. 

Sec. II. — State of the Mind. — The mind is almost always 
more or less affected, from the commencement of the disease. 
This affection may consist, for the first few days, merely in a 
diminution of its usual strength and activity. The patient feels 
himself confused and cloudy, and hesitating in his thoughts. 
His accustomed aptitude for intellectual effort is lost. Dr. Ger- 
hard says that, in the Philadelphia epidemic of 1836, " the alter- 
ation of the intelligence was so slight at first as to escape the 
attention of an inexperienced observer ; but when the fever had 
fully set in, there was at least confusion of the intellect, and 
nearly always delirium. This last symptom was absent in only 
a few cases. The delirium was not noisy, except in about one 
patient out of twenty. In the immense majority of patients, it 
was dull, muttering, and incoherent. The delirium became more 
tranquil, and was exchanged for ordinary stupor, or coma, when 
the fever was at its height. It did not cease entirely until the 
complete establishment of convalescence. Even after recovery, 
the intellect of the patient was more enfeebled than it is in ordi- 
nary diseases, and regained its usual strength but slowly." 

In the Irish epidemic at Cork, already spoken of, Dr. Pickels 
says : " The patient commonly raved of those objects which had 
principally engrossed his attention during health. A cow-herd, 
who had been brought in from the country, fancying that the 
patients who lay around him were those animals which he had 
been accustomed to attend, endeavored at intervals to rouse them 
into motion by a particular cry, which is usual for this purpose in 
the country. A thief raved of his thefts and accomplices. A 
faithful steward refused, with many acknowledgments, to take 

1 Edinburgh Med. and Surg. Journ., Oct. 1840. 



208 TYPHUS FEVER. 

his wine, as he had his master's keys, and it might render him 
unfit to perform his business." Hildenbrand says: " During the 
septenary stage of an attack of typhus, my mind was constantly 
engaged in removing an awkward ornament from my stove, which 
stood directly opposite to me; and, being of course unable to 
remove it, it tormented me in the most cruel manner. One of 
my pupils, who, having been taken with an attack of typhus a 
short time previously, had assisted at the opera called the Mirror 
of Arcadia, performed, during the whole septenary of the nervous 
stage, the character of viper-catcher ; and as he was obliged to 
swallow these disgusting reptiles, he experienced the most inex- 
pressible anxiety. Another labored under the painful and fantas- 
tic idea, during the whole course of his disease, that he was not 
only suffering for himself, but for all his comrades in the clinical 
ward." 1 Dr. John Cheyne informs us, in his account of typhus 
fever at the Hardwicke Hospital, Dublin, in the summer of 1818, 
that, in severe cases, delirium came on at the end of the first or 
at the beginning of the second week. " At all times, such pa- 
tients were incapable of any stretch of attention ; they answered 
questions satisfactorily, though with a faltering voice, but soon 
wandered from the subject. In many cases, the delirium was of 
a very troublesome kind; first, it Was only occasional; then, it 
continued all night ; then it was uninterrupted. We had many 
patients who created great disturbance by wandering about the 
wards all night, prying into the closets, and looking under the 
beds. Some of these were full of their usual occupations : one 
man, by trade a cooper, endeavored to pull his bed to pieces, in 
order to make a tub of the spars." It ought, perhaps, to be 
stated here, that many of the patients in the Irish hospitals were 
habitual spirit drinkers ; and it is very probable that, in some of 
these cases, the elements of delirium tremens may have been 
combined to some extent with those of the fever itself. 

In twenty-three cases amongst females, noticed by Dr. Hen- 
derson, at Edinburgh, the delirium began on an average about 
the eleventh day. Dr. Henderson found no appreciable relation 
between the disturbance of the mental powers and the degree of 
pain in the head. The average date at which delirium showed 
itself amongst male patients was about the tenth day : it oc- 

1 Gross's Hildenbrand, p. 45. 



SYMPTOMS. — STATE OF THE MIND. 209 

curred, also, in a greater proportion of cases amongst males, and 
was oftener of a violent character. 

The following is Dr. Jenner's account of the state of the mind 
in his forty-three fatal cases : " The mind of one patient was 
perfect throughout the disease. This was a very mild case in 
every particular ; the patient died of phlebitis after he had once 
left his bed. In another case there was only slight mental con- 
fusion; this patient also survived the fever. Although there was 
no actual delirium in thirteen other cases, yet there was in them 
such extreme mental confusion that the patients could give no 
account of their past state, 'felt bothered,' had no idea how long 
they had been in the hospital, nor in some cases where they 
were. Delirium began in ten cases respectively, on the fifth, 
eighth, tenth, tenth, tenth, eleventh, eleventh, eleventh, twelfth, 
and thirteenth day. It was present when five cases first came 
under observation, severally on the sixth, eighth, ninth, ninth, 
and fourteenth day. In every instance in which the delirium 
commenced after the patients entered the hospital, excepting 
one, it was preceded by a varying amount of mental confusion. 
It was uncertain how long nine patients had been ill, who were 
delirious when I first saw them. Four patients were admitted 
into the wards in a state of complete stupor. The delirium con- 
tinued till the death of the patients in thirteen cases, nine of 
which proved fatal, severally on the ninth, eleventh, eleventh, four- 
teenth, sixteenth, seventeenth, seventeenth, nineteenth, and twen- 
tieth day. The remainder of the forty-three patients either sunk 
into a state of absolute coma, or survived the termination of the 
fever. The character of the delirium was usually far less active 
than that of the delirium of typhoid fever ; the patients displayed 
less vivacity, and fewer of them, seven only of the twenty-four, 
i. e. at the rate of 29.2 per cent, of those who were delirious 
after they were admitted into the hospital, attempted to leave 
their beds to roam in the wards." 1 

Another very constant symptom belonging to this group con- 
sists of somnolence, or stupor, in its various degrees. This is 
amongst the earliest phenomena of typhus fever. Dr. Gerhard 
says: " It was perceptible in our patients, from the moment when 
they complained of their first symptoms. It was frequently slight, 

1 Jenncr on Typhoid, &c, p. 23. 

u 



210 TYPHUS FEVER. 

but could always be recognized by a little attention, and gradu- 
ally increased until the middle period of the disease, when it was 
most intense ; nor did it cease entirely until the strength of the 
patient had returned. There were usually some traces of it dur- 
ing convalescence. The stupor rarely passed into complete coma, 
except in fatal cases ; hence coma was always a most unfavorable 
sign. Still, to a moderate extent, it was occasionally witnessed, 
without being followed by the same danger as in ordinary dis- 
eases." Dr. Pickels observes that, in cases marked by stupor, 
even where there had been no delirium, the patients, upon re- 
covery, seemed to have lost all recollection of what length of 
time they have been sick. 

Somnolence was present in twenty-seven of Dr. Jenner's forty- 
three fatal cases. Nine patients had coma vigil, from one to 
four days immediately preceding death. " By this term," says 
Dr. Jenner, "I mean to express that peculiar condition in which 
the patient lies with his eyes open, evidently awake, but indif- 
ferent or insensible to all going on around him, and not what 
some writers on fever have meant by the expression, viz., that 
state in which the patient lies asleep for hours, and yet declares, 
on awakening, that he has never closed his eyes." 1 

The sleep is imperfect, unrefreshing, and disturbed ; and it 
continues to be so until it lapses gradually into coma, or until 
the patient falls into the deep and sweet repose of commencing 
convalescence. 

Sec. III. — Physiognomy. Besides the dull and stupid ex- 
pression of the countenance, common both to typhoid and to 
typhus fever, there are other appearances of the face more cha- 
racteristic of the latter disease. These consist in a peculiar 
state of the skin and the eyes. They are very generally men- 
tioned by writers on typhus fever, and are particularly described 
by Dr. Gerhard. "A constant symptom," he says, "observed 
in every case, was a dull, livid, red hue of the countenance, ex- 
tending nearly over its whole surface. Sometimes, this color ap- 
proached a purple. It coincided with a strong, dark red suffusion 
of the capillary vessels of the conjunctiva, which appeared at 
the same time with it ; but it usually disappeared at an earlier 

1 Jenner on Typhoid Fever, &c. p. 24. 



SYMPTOMS. — PHYSIOGNOMY. — SENSES. 211 

stage than the injection of the eyes. The conjunctiva never 
presented the bright red tinge, or the brilliant aspect, observed 
in acute inflammatory diseases of the brain, or of the eye itself. 
Dr. Jenner says : " The conjunctivae were more or less in- 
tensely injected in twenty-five cases : and in all of those in 
which the opportunity occurred of observing the date of the first 
appearance of this increased vascularity, it began during the 
second week. * * * In eleven of the cases, the pupils 
were contracted. The expression was dull, and the blood-vessels 
had a dark-red tinge, instead of their usual scarlet hue. The 
suffusion of the face and eyes was so constant, and so well 
marked, in the fully formed disease, that it served almost as a 
pathognomonic sign. It was generally most evident in patients 
of a full habit of body. Towards the close of the disease, the 
reddish color was gradually changed into a dull ashen tint, which 
remained until the entire recovery of the patient." 1 

Dr. Jenner says : "In none of the forty- three cases was the 
expression natural throughout the disease. In a large majority 
of the cases, both the expression and the manner of the patient 
were so peculiar, that from them alone the diagnosis might have 
been formed. They were dull, heavy, oppressed, confused like 
those of a drunken man just disturbed from sleep. The mind 
was rarely intelligent enough after the commencement of the 
second week to be disturbed as to the final issue, and as the dis- 
ease in itself is free from serious organic lesion, all automatic as 
well as mental expression of anxiety was absent. The hue of the 
face after about the 6th day was, like the expression and manner, 
peculiar — it was thick and muddy looking ; the change from this 
condition to the clearness of health was most remarkable. * * * 
The muddy hue had no relation to the flush of the face, for it was 
often present when the face was pale ; moreover, though only 
noted in the face, it affected more or less the whole skin. The 
face was flushed in eighteen cases, and in every case the flush 
covered the whole face, though in some it might have been some- 
what more intense on the cheek than elsewhere. The color of 
the face when flushed was dusky red, and never pink, as the cheeks 
were in the cases of typhoid fever." 2 

1 Jenner on Typhoid, &c. p. 28. * Ibid., p. 20. 



212 TYPHUS FEVER. 

Sec. IV. — State of the Senses. Several of the senses are com- 
monly more or less perverted in the course of typhus fever. 
Some confusion of vision is frequently present, from the begin- 
ning of the disease. This is often associated with dizziness, 
especially on assuming the sitting or upright position. Dulness 
of hearing, commonly connected with ringing in the ears, is also 
an early and a very common symptom. Dizziness was present 
in five of nine cases, observed at London by Dr. Shattuck, Jr., 
and dulness of hearing in only one. Dr. Stewart mentions great 
intolerance of light, as one of the most constant symptoms of the 
disease. 

There is often a morbid sensibility of the entire surface of the 
body. Dr. Gerhard observed, in the Philadelphia epidemic of 
1836, that "the sensibility of the skin was universally augmented 
when the stupor was not so great as to render the patient insen- 
sible, or nearly so, to all external impressions. The tenderness 
upon pressure was so much increased as to induce us to refer the 
external soreness at the epigastrium, when pressure was made 
upon the abdomen, to an affection of the internal organs ; but on 
more careful examination, the sensibility was nearly equally in- 
creased in every part of the body, and was evidently external. 

"The cutaneous tenderness was preceded by muscular sore- 
ness, which lessened as the skin became more sensitive." 

Sec. Y. — State of the Muscles. Amongst the earliest and most 
constant accompaniments of typhus fever, is loss of muscular 
strength. This is almost invariably present from the beginning 
to the close of the disease. Even during the premonitory stage, 
when this exists, it is with much difficulty and effort that the 
patient succeeds in keeping from his bed. Dr. Pickels, in his 
Report on the Typhus Fever at Cork, says: "The debility was 
such that the patient was unable, from the commencement, to rise 
from the bed, or to walk without assistance, and in some instances, 
even without the effort of rising, fainted in bed. In a few, syn- 
cope appeared, as the first symptom of the onset of the disease." 
In thirty-four of Dr. Jenner's forty-three fatal cases, there was ex- 
treme prostration ; and in a large majority of these cases, this ex- 
treme prostration came on from 9th to the 12th day of the disease. 1 

1 Jenner, &c. p. 27. 



SYMPTOMS. — TONGUE AND MOUTH. 213 

" There is a secondary and still more extreme prostration of 
strength, which comes on on the subsidence of the fever, and is 
attended with coldness of the extremities, and a feeble, fluttering 
pulse." 1 

Spasmodic twitchings of the muscles are very common in typhus 
as they are in typhoid fever. Their positive frequency, I am 
not able to give. Dr. Gerhard observed subsultus of the tendons 
at the wrist in three-fourths of his patients. " In the more severe 
cases," he says, "the subsultus extended to the muscles of the 
legs and face. When it appeared at the face, the corners of the 
mouth were drawn rapidjy to one side or the other, giving a singu- 
lar expression to the countenance. In the worst cases, the sub- 
sultus extended to nearly all the muscles of the body, keeping 
the patient in a constant state of tremor, not unlike a severe chill. 
The smaller muscles were much more affected than the larger ones, 
and there was no constant rigidity observed in any case ; neither 
was there any paralysis." It will be seen, from what has now 
been said, that the symptoms connected with the nervous system 
are even more constant and more strongly marked in typhus than 
in typhoid fever ; but that there is no very constant or important 
difference between them, unless it be in the greater degree of 
stupor attending the former, in the lower grade of the delirium, 
and in the earlier and more rapid development of these symptoms. 

ARTICLE V. 

DIGESTIVE AND ABDOMINAL SYMPTOMS. 

Sec. I. — Tongue and Mouth. The appearance of the tongue 
in this disease is very various. In mild cases, it frequently con- 
tinues moist, and is merely covered with a light- colored, thin 
coating ; this may become brownish, as the disease proceeds. In 
other and in grave cases, the tongue is dry, cracked, glazed, 
trembling when protruded from the mouth, and of various shades 
of color, from the light brown already mentioned to black. It 
may be of a deep glossy red color. Sometimes, and in certain 
stages of the disease, it has a dark, yellowish or brown, dry 
stripe along its middle, while the edges are nearly clean and 

1 Amer. Joura. Med. Sciences, Aug. 1887. 



214 TYPHUS FEVER. 

moist. Dr. Henderson studied the state of the tongue very care- 
fully in a large number of cases at Edinburgh, in 1838 and 1839. 
" It very early became covered," he says, "with an increased and 
altered secretion ; white, yellow, or ash-colored ; viscid, and ad- 
hering to the surface, becoming commonly thicker and darker 
as the disease advanced. A dry state of the tongue began chiefly 
in the second week of the fever, and continued for the most part 
without change until, along with other symptoms of convale- 
scence, the tip and edges assumed a moist and clean appearance, 
which gradually extended to the rest. The dryness was often 
confined to the centre of the tongue, extending in a brown streak 
from the point backwards." 1 Accompanying these morbid states 
of the tongue, there is very frequently an accumulation^ dark 
sordes upon the teeth and gums, and fetor of the breath. Dr. 
John Cheyne, in his Hardwicke Hospital Report, for 1818, says, 
that there was often an inability to protrude the tongue, which 
very awkwardly obeyed the will of the patient. " He would open 
his mouth, and after various unsteady motions, at length force 
out his tongue ; and when this was accomplished, it was not again 
drawn within the mouth until he was repeatedly admonished to 
that effect." Dr. Jenner says the tongue is more uniformly dry 
and brown in typhus than it is in typhoid fever. 2 

Sec. II. — Appetite. The appetite is generally destroyed, al- 
though it would seem to be less constantly and entirely wanting 
in typhus than in typhoid fever. Amongst the blacks at Phila- 
delphia, in 1836, the appetite sometimes continued, and some of 
them asked for and ate solid food. At the Cork Street Fever Hos- 
pital, during the summer of 1816, when the prevailing character 
of the fever was very mild, Dr. William Stoker noticed, as a re- 
markable peculiarity, the continuance of a considerable degree of 
appetite, even whilst the fever was urgent. In two fatal cases, 
a desire for food was expressed a few hours before dissolution. 

Sec. III. — Nausea and Vomiting. Nausea and vomiting are 
occasionally present at the commencement of the disease ; but 
the proportion of cases in which they occur, and the difference 
in this respect, if any such exist, between typhus and typhoid 

1 Edin. Med. and Surg. Journal, Oct. 1839. 2 Jenner, &c. p. 29. 



SYMPTOMS. — STATE OF THE BOWELS. 215 

fever, I have no means of ascertaining. In the Philadelphia 
epidemic of 1836, both nausea and vomiting were extremely rare. 
Dr. Gerhard says that he scarcely found either of these symptoms 
noted in a single case. There may be a good deal of difference 
in their frequency, in different seasons and localities. I have 
already stated, that Dr. Pickels says the fever at Cork, in 1817, 
1818, and 1819, was, in almost every instance, preceded by 
nausea, or, as the patient expressed it, by an empty straining. 
Dr. Anderson says that nausea was present in fourteen of 
eighteen cases observed by himself, on the first day of the disease. 
In nine cases observed by Dr. Shattuck, at the London Fever 
Hospital, there was neither nausea, vomiting, nor epigastric pain. 
Amongst one hundred and thirty-two female patients treated at 
the Royal Infirmary of Edinburgh, in 1838 and 1839, nausea 
and vomiting were ascertained to have been present in only 
twelve, chiefly at the beginning of the fever. 

Sec. IV. — State of the Bowels. In a majority of cases, there 
is very little if any obvious change either in the shape or feel of 
the abdomen. When it is all tympanitic, it is only slightly so. 
Dr. Gerhard says that, in many patients, it was either retracted 
or altogether of the natural form. Dr. Stewart found moderate 
meteorism in only seventy-four of four hundred and sixty-three 
cases. Tenderness on pressure, either over the whole abdomen 
or over the epigastrium, is frequently spoken of by writers on 
typhus fever ; but it is probable that, in many cases, this has de- 
pended upon the morbid sensibility of the skin. Of Dr. Shattuck's 
nine cases, there was meteorism in only one ; and in this, but for 
a single day. Of Dr. Jenner's forty-three cases, there was ten- 
derness of the abdomen at some period of the disease in nine 
cases, but in eight of them it was trivial and transient. Gur- 
gling was detected in only a single case. The abdomen in twelve 
of forty-one cases was full and resonant, in three only of these 
twelve was it unnaturally distended, and in neither of the three 
was it noted to possess the peculiar shape of the typhoid abdomen. 
In twenty-two cases there was neither fulness, resonance, ten- 
derness, nor gurgling ; in these twenty-two cases the abdomen 
presented all the physical signs of health, and in two of them it 
was noted to be somewhat concave. 1 

1 Jenner, &c. p. 31- 



216 TYPHUS FEVER. 

Oftener than otherwise the howels in typhus fever are con- 
stipated. This is as true of grave as it is of mild cases ; and it is 
also as true of the late as it is of the early periods of the disease. 
Spontaneous diarrhoea is as rare a symptom in typhus as it is a 
common one in typhoid fever. It is hardly seen, indeed, in the 
former disease, excepting during certain seasons, especially in the 
summer and autumn, -when there exists a general predisposition to 
intestinal irritation and inflammation. Under such circumstances 
typhus fever feels, as any other disease might, the influence of 
the prevailing pathological tendency. Br. Stewart found diar- 
rhoea in only twenty-three of one hundred and thirty-nine cases. 
Dr. Henderson, in one hundred and fifty-four cases of typhus, 
found the bowels easy in ninety-nine, loose in five, and .costive 
in fifty. Dr. West, in his paper on Exanthematic Typhus, 
says: "The action of the bowels was not disturbed, in the great 
majority of cases ; in fact, the administration of mild laxatives 
was necessary, in most instances, in order to obtain an evacuation 
once in forty-eight hours ; and in some of the most severe cases, 
the bowels were very constipated. Diarrhoea occurred in only 
ten of sixty cases ; in three of which the patients died, and it 
was only four times that it lasted longer than forty-eight or sixty 
hours." " The intestinal evacuations," says Dr. Henderson, "in 
their most disordered state, were very dark, slimy, and offensive ; 
and in a more or less considerable degree they possessed these 
characters in almost every case ; a few only of the mild and one 
or two of the protracted cases having had throughout stools of 
a light yellow color." Dr. Edward Percival speaks of the 
stools in a certain number of cases, as being "unctuous or pitchy, 
of a black or greenish hue, and either preternaturally fetid or 
unusually inodorous." Many of Dr. Jenner's patients required 
aperients. The discharges were rarely watery, and in only one case 
was there any considerable diarrhoea. Hemorrhage did not occur 
in a single case. 1 

Epigastric distress and tenderness are spoken of by Dr. Cheyne 
and by many others as frequently present, especially during the 
summer and autumn, when there are other symptoms of disturbance 
of the stomach. Of one hundred and thirty-nine cases reported 

1 Jenner, &c. p. 33. 



SYMPTOMS. — EMACIATION. — STATE OF THE URINE. 217 

by Dr. Stewart, there was abdominal pain, somewhat permanent, 
in ninety-six ; and in sixty of these it continued throughout the 
greater part of the illness. In most cases the pain was general, 
in thirty-two it was chiefly or entirely confined to the region of 
the liver, and in half of these it was associated with great ten- 
derness on pressure. In eleven instances only was there any 
pain in the right iliac region. Dr. Stewart observes that, while 
in typhoid fever the pain accompanies the diarrhoea, in typhus 
the pain is often most severe when the bowels are costive, and is 
relieved by the exhibition of a purgative. 1 Dr. Stewart found, 
indeed, that of seventy-seven cases of typhus in which diarrhoea 
either spontaneous or consecutive was noticed, there was accom- 
panying abdominal pain in only thirty ; while of sixty-two cases 
in which the bowels were confined, abdominal pain and consti- 
pation coexisted in no less than twenty-one. A similar relation 
between these two symptoms was noticed by Dr. West. It can 
hardly be necessary for me to call attention to the very wide and 
striking difference between the abdominal symptoms in typhus 
and typhoid fever. 

Hemorrhage from the bowels is of extremely rare occurrence. 
Dr. Henderson saw only one instance of this, amongst two hun- 
dred patients, at the Royal Infirmary of Edinburgh, in 1838 and 
1839. 



ARTICLE VI. 

MISCELLANEOUS SYMPTOMS. 

Sec. I. — Emaciation. There is not much obvious wasting of 
the body, in the early periods of typhus fever. Dr. Gerhard 
did not find it to become very evident until the fever began to 
decline. 

Sec. II. — State of the Urine. I am not aware that the changes 
in the quantity and character of the urine in typhus fever have 
been to any great extent accurately studied. Dr. Gerhard says 
that, in the Philadelphia epidemic, the urine " was examined very 

1 Edin. Med. and Surg. Journ., Oct, 1840. 



218 TYPHUS FEVER. 

attentively, and was remarkable merely for its extraordinary free- 
dom from brick-red deposit, or the changes so frequently observed 
during the course of fever." Dr. Edward Percival says that the 
quality of the urine is too variable to place any dependence, upon 
it. This, however, is in reference to prognosis. Dr. William 
Stoker says that, in the early stages of the disease, the urine is 
scanty and high-colored. Retention of the urine is not uncom- 
mon in bad cases,, constituting a distressing, and, if overlooked, 
as it is very likely to be, a dangerous complication. 

This seems to be more common in typhus than in typhoid 
fever. It was present in eleven of Dr. Jenner's forty-three fatal 
cases. " Either retention or involuntary discharge of urine was 
a symptom in twenty-one, or in nearly one-half of the patients ; 
and as no notes on the point were taken in seven cases in which 
the prostration was extreme, it is probable that considerably 
more than one-half were thus affected." 1 

Sec. III. — Epistaxis. Hemorrhage from the nostrils, so com- 
mon in typhoid, seems to be not a very frequent occurrence in 
typhus fever. Dr. Gerhard does not mention it at all. By some 
writers, however, it is spoken of as a more common and important 
symptom. Dr. Pickels, in his report on the Cork epidemic, says : 
" Bleeding from the nose, though often occurring separately, in a 
majority of instances appeared in petechial cases. The discharge 
did not usually exceed a few drops, but continued to recur during 
some days. In two cases, however, which proved fatal, the dis- 
charge was so profuse as to fill vessels of considerable size. 
Bleeding from the nose came on in a majority on the second 
day, rarely appearing later than the seventh; it was much more 
common amongst males than females." Dr. F. Barker speaks 
of its occurrence occasionally, and adds that no other hemor- 
rhage is common. It was not present in any of Dr. Jenner's 
cases. 

Sec. IV. — Cutaneous Eruptions. Typhus fever is very gene- 
rally attended with a peculiar and characteristic eruption upon 
the skin. The name of the disease has often been derived from 

1 Jenner on Typhoid, &c. p. 26. 



SYMPTOMS. — CUTANEOUS ERUPTIONS. 219 

this circumstance ; hence it has been called petechial fever, 
spotted fever, maculated fever, and so on. As to the exact fre- 
quency of the occurrence of this eruption, it is impossible to 
speak with entire certainty. In many cases it has probably been 
overlooked ; and besides this, it is to be remembered that the 
diagnosis of typhus fever, by many who hav ewritten most ex- 
tensively and most magisterially upon the subject, has been any- 
thing but rigorous and careful. Dr. Stewart remarks, " that 
the eruption of typhus was unnoticed at Edinburgh, until the at- 
tention of physicians was called to it by Dr. Peebles in 1832." 
He says further : ** It is also well known to many that, previous 
to a visit which Dr. Peebles made to the Glasgow Fever Hospital 
in the spring of 1835, the exanthema of typhus, then found to 
be of general occurrence, had neither been looked for nor regis- 
tered in that institution, and was received as a new discovery." 
These considerations may help to account for the differences 
which are to be found in different histories of the disease in re- 
lation to this particular subject. In the Philadelphia epidemic, 
Dr. Gerhard says: " It was present in thirty-two of thirty-six 
whites. Of the four cases in which it was not visible, one died 
upon the seventh day of the disease, and the others presented 
slight symptoms of fever, which disappeared in the course of 
four or five days. It was also visible, though less distinctly, in 
mulattoes ; and we may infer that the color of the skin alone pre- 
vented its development in the negroes." 

This eruption differs in many respects, and in a very striking 
degree, from that of typhoid fever. Its color, especially after 
the second or third day of its appearance, is that of a duller 
and darker red. The spots are of a dun, dusky, purplish hue ; 
in some cases they become almost black. They vary in size, 
from that of a minute point to a diameter of a line, or even of 
an eighth of an inch. They are less regularly circular or oval 
than the rose spots of typhoid fever. They are not elevated 
above the surrounding skin, and disappear but very partially, or 
not at all, on pressure. They are almost always much more nu- 
merous than the spots of typhoid fever; covering in many cases 
the entire trunk and the extremities. Sometimes, they are spread 
over the skin almost as thickly as the eruption of measles. Dr. 
Pickles says that, in the Cork epidemic, " the spots were princi- 
pally observed upon the breast, neck, shoulders, arms, and thighs; 



220 TYPHUS FEVER. 

rarely upon the face. From their resemblance in some instances 
to freckles, the friends of the patients, in their descriptions at 
the dispensary, sometimes compared the appearance of the skin 
covered with them to that of a turkey's egg. The mottled or 
marbled efflorescence, resembling measles, occurred in several." 1 
Huxham says : " We frequently meet with an efflorescence, also, 
like the measles, in malignant fevers, but of a more dull and lurid 
hue, in which the skin, especially on the breast, appears as it 
were marbled or variegated." Pringle's description of the erup- 
tion is in these words : " There are certain spots, which are the 
frequent but not inseparable attendants of the fever in its worst 
state. These are less usual on the first breaking out in the hos- 
pitals ; but when the air becomes more corrupted the spots are 
common. They are of the petechial kind, of an obscure red 
color, paler than the measles, not raised above the skin, of no 
regular shape, but confluent. The nearer these spots approach 
to a purple color, the more ominous they are, though not abso- 
lutely mortal." The eruption sometimes fades suddenly, or 
changes in its color. Dr. Stewart, amongst others, has, within a 
few years, studied with great care and particularity the character 
and appearances of this eruption. He says that the rash is per- 
manent ; that is, that it does not consist of successive eruptions 
of spots ; that, in all cases, it presents the two periods, longer or 
shorter, of increase and decline ; and that, in the more severe 
cases, it may exhibit during the period of increase four different 
states, being florid, dark, livid, and petechial. When the hue of 
the eruption is florid, it disappears readily under pressure ; when 
dark, it still disappears, but more slowly ; when livid, semi-pete- 
chial, or pseudo-petechial, as it has been called, it is only partial- 
ly effaced; and when petechial, it is not in the least affected by 
pressure. In many cases, it remains florid throughout ; in others, 
it presents one or more, and in not a few all these alterations ; and 
after it has reached its height the process is inverted, and it 
passes through the various phases of lividity, darkness, redness, 
and paleness, before its evanescence." Of one hundred and 
thirty-nine cases of typhus observed by Dr. Stewart, the erup- 
tion was pale in about one-fourth, florid in between one-sixth 
and one-seventh, darkish in between one-eighth and one-ninth, 

1 Trans, of Pays, of Ireland, vol. iii. p. 199. 



SYMPTOMS. — CUTANEOUS ERUPTIONS. 221 

livid in rather less than one-ninth, and petechial in about one- 
eighth. 

Dr. Stewart ascertained the exact time of the appearance of 
the eruption in fifty-two cases. This time varied from the second 
to the thirteenth day ; but in twenty-nine cases, more than 
half of the entire number, it appeared on the fifth or sixth day; 
and in three-fourths it appeared from the fourth to the seventh 
day. In forty-eight cases the eruption began to decline at differ- 
ent periods, from the eighth to the nineteenth day. It was still 
more irregular in the time of its disappearance, since this ranged 
from the thirteenth to the thirty-first day. The average duration 
of the eruption was eleven and a half days. 1 

Dr. Henderson, of Edinburgh, has also observed, with an atten- 
tion and thoroughness not inferior to those of Dr. Stewart, the 
appearances of the cutaneous eruption, and very generally with 
similar results. Dr. Henderson noticed that, as a general rule, 
the progress and development of the eruption corresponded with 
the increasing severity of the other symptoms of the disease; and 
that, in like manner, the decline of the eruption was nearly 
simultaneous with the first signs of convalescence. He found, 
also, that the mortality and duration of the disease were very 
noticeably proportionate to the abundance of the eruption. Con- 
valescence was more protracted in those cases where it was 
abundant than in those where it was scanty. 2 

In Dr. Gerhard's cases, the eruption appeared from the sixth 
to the eighth day after the commencement of the disease, and 
gradually faded away and disappeared, from the fourteenth to 
the twentieth. 

The importance of this eruption, as one of the diagnostic marks 
of typhus, induces me to add to the foregoing the minute and 
precise description of Dr. Jenner. He calls it the mulberry rash 
peculiar to typhus fever. " The eruption was never papular. Its 
characters varied with its duration. On the first appearance of 
the rash, it consisted of very slightly elevated spots of a dusky 
pink color. Each spot was flattened on the surface, irregular in 
outline, had no well-defined margin, but faded insensibly into the 
hue of the surrounding skin, disappeared completely on pressure, 
and varied in size from a point to three or four lines in diameter. 

1 Edinburgh Med. and Surg. Journal, Oct. 1SI0. 2 Ibid., Oct. 1839. 



222 TYPHUS - FEVER. 

The largest spots appeared to be formed by the coalescence of 
two or more smaller, and the shape of the former accordingly 
was more irregular than that of the latter. 

" Second Stage. — In one, two, or three days, these spots under- 
went a marked change ; they were no longer elevated above the 
surrounding cuticle, their hue was darker and more dingy than 
on their first appearance, their margins rather more, but still 
imperfectly defined, and now they only faded on pressure. In 
this stage they were usually darker, less affected by pressure, and 
their margins more defined on the posterior than on the anterior 
surface of the body. In some cases the spots after this grew 
paler, passed into faintly-marked reddish-brown stains, and then 
disappeared. 

"Third Stage. — In others, a third stage was reached; the cen- 
tres of the spots became dark purple, and remained unaltered by 
pressure, although their circumferences still faded ; or the entire 
spots, the circumferences as well as the centres, changed into 
true petechia, i. e. spots presenting the following characters : a 
dusky crimson or purple color, quite unaffected by pressure, a 
well-defined margin, and total want of elevation above the level 
of the cuticle. This alteration was most frequently observed to 
take place on the back, at the bend of the elbow, and in the 
groin. At the bend of the elbow they were generally oval, their 
long axis lying in the direction of the long axis of the arm. In 
a large majority of the cases the spots were very numerous, close 
together, sometimes almost covering the skin. In a few instances, 
however, they were comparatively few in number, very pale, and 
situated at some distance from each other. 1 The usual situation 
of the spots was the trunk and extremities, but occasionally they 
were limited to the trunk, and now and then were observed on 
the face. Their number reached its maximum on the first, second, 
or third day, no fresh spots appearing after the latter date, and 

1 In these cases, on the first day of their appearance, they occasionally bore so 
close a resemblance to the rose spots, that, although they were never altogether 
identical with the best-marked specimens of the latter, yet the most tutored eye 
might be in some doubt as to which order they belonged ; and when the general 
symptoms were at the same time equivocal, the diagnosis was impossible till a 
day or two had elapsed, when some or all the spots passed into their second 
stage ; whereas, if they had been the spots peculiar to the typhoid fever, they 
would have retained the characters they presented on the first day till they disap- 
peared altogether on the third or fourth day after their eruption. 



SYMPTOMS. CUTANEOUS ERUPTIONS. 223 

each spot remained visible from its first eruption till the whole 
rash vanished. 

" When very numerous, the whole of the spots seen together on 
the surface had not an equal depth of color ; many were much paler 
than the others, and had a dull appearance, as if seen through 
the cuticle. In my notes, I have been in the habit of distinguish- 
ing these collectively as the subcuticular rash. It often, by its 
abundance, gave a mottled aspect to the skin, on which ground 
the darker spots were seated. Variations in the absolute or re- 
lative amount of the subcuticular rash and of the spots, as well 
as in the depth of their respective color, cause much difference 
in the general appearance of the rash. Sometimes it resembles 
measles so closely as to be distinguished from it with difficulty ; 
at others, it presents that appearance which has been called spotted 
rash ; and again, it is sometimes so pale that, unless carefully 
looked for, it might be passed over altogether. When the spots 
on the back were of a much deeper hue than those on the ante- 
rior surface of the trunk, the skin covering the posterior surface 
was generally considerably congested. Slight pressure of the 
finger leaving a white mark, which slowly returned to its previous 
dusky red color. 

"To sum up : — 

"1. The mulberry rash was present in all the cases. 

"2. The rash usually appeared from the fifth to the eighth day 
of the disease. 

"3. Fresh spots never appeared after the second or third days 
of the eruption. 

"4. The duration of each spot was from its first appearance 
till the death or recovery of the patient from the attack of ty- 
phus. 

"5. The rash disappeared between the fourteenth and twenty- 
first days of the disease ; when death ensued after the latter 
date it was the result of local disease, which either complicated 
the progress of the fever, and continued after that had run its 
course, or sprung up anew, connected or not with the enfeebled 
state of constitution, the consequence of the fever. 

"6. In no case was there any return of the eruption, and, 
therefore, no true relapse." 1 

1 Jenner, &c. pp. 14-17. 



224 TYPHUS FEVER. 

Other eruptions, but none of them at all constant or charac- 
teristic, are occasionally observed in this disease. Amongst them 
is that of sudamina, which is sometimes seen, but not so fre- 
quently as in typhoid fever. A miliary eruption now and then 
shows itself over the whole body, remains for a few days, and 
then disappears ; the elevated cuticle falling off in a fine, branny 
desquamation. Vibices are occasionally though rarely seen, 
near the fatal close of the disease. Dr. Stewart met with them 
in only two of one hundred and thirty-nine cases, and with pur- 
pura spots in only three. Dr. Henderson saw only one vibex 
amongst two hundred patients, and sudamina in only three. 

In grave cases, there is sometimes noticed a dark livid or purple 
color of the skin of the extremities ; oftenest in the early, but 
sometimes continuing through the entire period of the disease. 

Sec. Y. — Eschars. Gangrenous sloughs and ulcerations seem 
to be common in some epidemics of typhus fever, and rare in 
others. At Philadelphia, in 1836, they were present in only 
three or four cases in a hundred. Dr. Pickels says that gangrene 
of the hips, nates, and shoulders was frequent during the epi- 
demic at Cork, in 1817, 1818, and 1819. Dr. O'Brien, in his 
Cork Street Hospital Report for 1820, informs us that ulcera- 
tions and gangrene of the hips, nates, and sacrum were of very 
common occurrence, few of the malignant and protracted types 
of fever being exempt from them. Dr. Percival, of Dublin, 
says: "Gangrenous extremities were extremely rare amongst my 
patients." 

Sec. VI. — State of the Blood. Amongst these miscellaneous 
symptoms may be mentioned the condition of the blood when 
drawn from the body. In the epidemic at Philadelphia, the blood 
was examined in various stages of the disease, except where the 
state of the patient was such as to render the operation of blood- 
letting clearly improper. " At a very early period it was dark, 
without the buffy coat, and offered a large but soft and dark- 
colored coagulum. At a more advanced stage it presented, in 
some patients, the dissolved appearance described by various 
authors as characteristic of the typhus or putrid fevers." Dr. 
O'Brien says: "In those instances where blood was taken in the 
advanced period of the disease, I have always found its texture 



SYMPTOMS. — STATE OF THE BLOOD. 225 

broken down and dissolved, changing rapidly into a greenish, 
watery fluid, with little coagulum ; indicating great dissolution of 
the animal fluids, and consequent great debility." 1 Huxham has 
described quite fully, in his usual rich and excellent manner, the 
altered state of the blood in typhus. 3 

1 Trans, of Phys. of Ireland, vol. i. p. 424. 
Huxham on Fevers, p. 41, et seq. 



15 



226 



CHAPTER III. 

ANATOMICAL LESIONS. 

The pathological alterations in fatal cases of typhus fever have 
not been so thoroughly and accurately studied as in those of 
typhoid fever. Our knowledge of the anatomical lesions and of 
the condition of all the organs after death, in the former disease, 
is of course much less complete than in the latter. Although 
the morbid anatomy of typhus fever has by no means been 
neglected by British observers, who have the best and most ex- 
tensive opportunities for its investigation, it is nevertheless true 
that it has not been subjected by them to such comprehensive, 
numerous, and detailed examinations, as the lesions in typhoid 
fever have undergone, at the hands of Louis, Andral, Chomel, 
Bouillaud, and others. 1 Amongst the most valuable and au- 
thentic materials for this portion of my history of typhus fever, 
are the results of the investigations of Drs. Gerhard and Pen- 
nock, during the Philadelphia epidemic of 1836. The number 
of autopsies made by these gentlemen during the prevalence of 
the disease was about fifty, and the fruits of their researches are 
especially valuable, on account of the entire confidence which we 
may feel in their competency as pathological observers, a con- 
fidence which we are forced to withhold from very many reporters 
of the morbid appearances in this as well as in other diseases. 
The paper of Dr. Gerhard does not contain any particular and 
formal description of the state of the several organs, and this 
description I shall be obliged to make up from the six individual 
cases, the anatomical lesions in which he has minutely detailed. 
During the years 1838 and 1839, Dr. John Reid, of Edinburgh, 
made careful and thorough examinations of the bodies of between 

1 This remark, made in my second edition, less than five years ago, is much 
less true now than it was then. The remarkable researches of Dr. Jenner have 
added very largely to our minute and accurate knowledge of the anatomical 
lesions of typhus. 



LESIONS. — THORACIC ORGANS. — LUNGS. 227 

forty and fifty patients who died with typhus fever at the Royal 
Infirmary of that city. These examinations are reported and 
analyzed and compared with the symptoms in a spirit the most 
philosophical, and with a completeness as rarely met with as it is 
worthy the highest praise. They constitute a very valuable ad- 
dition to our knowledge of the lesions in .this disease. 1 With the 
materials derived from these sources, and with such others as are 
accessible and trustworthy, I shall endeavor to make out as full 
an account of the pathological anatomy of typhus fever as, in the 
present state of science, it is possible to do. 

ARTICLE I. 
LESIONS OF THE THORACIC ORGANS. 

Sec. I. — Lungs. The morbid alterations which are found 
within the cavity of the chest seem to be not less constant and 
important in typhus than in typhoid fever. The lungs were more 
or less changed from their healthy condition in all the cases re- 
ported by Dr. Gerhard. This change generally consisted in a 
somewhat peculiar condensation of a portion of one or both lungs. 
The tissue of the lung was more solid and heavy than in its 
natural state ; quite or nearly impermeable to the air, sometimes 
friable and sometimes not so; of a dark and sometimes a livid 
red; not granular, like hepatization, but resembling in some de- 
gree, when torn, the structure of the spleen. This alteration 
was most frequent in the lower and posterior portions of the 
organs. The mucous lining of the trachea and bronchial tubes 
was in many cases of a rosy red color, sometimes with a livid 
tinge ; but it was rarely changed, either in thickness or consist- 
ence. 

In only two or three of thirty-five cases, examined by Dr. 
Jenner, were the lungs found free from disease. In three cases, 
there was simple congestion of the posterior part of the lungs. 
In three cases, there was congestion with diminished consistence. 
In eleven cases, there was congestion of the posterior part of the 
lung, with non-granular consolidation of the most depending 

1 Between 1839 and 1841, Dr. Reid made careful dissections in one hundred 
additional cases of continued fever. The results of these examinations will be 
found in the present edition. 



228 TYPHUS FEVER. 

layer of pulmonary tissue ; in some cases, extending to both 
lungs, in most limited to one. In four cases, there was more or 
less edema. In eight cases, there was lobular consolidation, 
granular or non-granular. In two cases, there was gangrene. 

The following is Dr. Jenner's description of the congestion of 
the posterior portion of the lung, with non-granular consolidation 
of the most depending part of the organ, a condition that he did 
not find after death from typhoid fever. " The posterior portion 
of the lung was congested, and its consistence diminished ; the 
most depending layer of pulmonary tissue (the subject being on 
Its back) which extended in different cases from a quarter of an 
inch to two inches into the substance of the lung, was solidified, 
very dark-bluish chocolate in color, gorged with non-aerated dark 
claret serosity, which flowed freely from the cut surface ; it was 
scarcely softened ; the whole of the solidified layer sank in water. 
The solidified portion was limited to the part of the organ which 
lies in the hollow formed by about the fourth, fifth, and sixth 
ribs. * * * The solidified and crepitant tissue passed im- 
perceptibly the one into the other." 1 

Of forty-three cases examined by Dr. Reid, in 1838 and 1839, 
there was more or less lesion of the lungs in all. In fifteen of 
these the lesion consisted of simple congestion, at the most de- 
pending portion of the organs ; in thirteen cases, the posterior 
and middle parts of both lungs were gorged with blood and 
frothy serum, and some portions were so dense as not to crepi- 
tate when cut, though they did not present any granular appear- 
ance; and in ten cases, there was increased effusion into the 
bronchial tubes. 2 In thirty-nine of these cases, the brain was 
also examined; and it appears, from a careful comparison, that 
extensive engorgement and congestion of the lungs were more 
frequently found associated with those cases in which there was 
increased serous effusion within the cranium than with those 
where this condition did not exist, indicating some special rela- 
tionship between the two phenomena. 3 

Sec. II. — Larynx and Pharynx. Dr. Jenner found un- 
equivocal traces of disease of the larynx or pharynx, or of both, 

1 Jenner, &c. p. 50. 

2 Between 1839 and 1841, Dr. Reid examined the lungs in eighty-eight fever 
cases, with much the same general results. — Edin. Med. Journ., Aug. 1842. 

* Edin. Med. and Surg. Journ., Oct. 1839. 



LESIONS. — HEART AND BLOOD. 229 

in nine of twenty-six cases. "The larynx and pharynx were 
deep purple, and covered with slimy mucus in one case. In four, 
there were unequivocal traces of inflammation in both organs ; 
thus, in one of the four, the mucous membrane of the pharynx 
was deep red, of the larynx vivid scarlet, the redness on minute 
inspection being found to be punctiform ; in another of the four, 
the lining membrane of the pharynx was of a dirty-yellowish 
color, and so soft that it was removable by the gentlest scrap- 
ing ; the chordae vocales swollen, the rima glottidis a mere chink, 
the mucous membrane of the larynx generally vividly injected 
and covered with muco-purulent fluid, and on the chordae vocales, 
and on the mucous membrane lining the larynx above the chords, 
were numerous shreds of white, opaque, lymph-like matter, readi- 
ly removable. In the third case, the lining membrane of the 
pharynx was covered with thick mucus, felt rough, apparently 
from enlargement of its follicles, and was of a dull purple color ; 
there was a small ulcer on either chorda vocalis, but no other 
trace of inflammatory action within the larynx. The pharynx 
in the fourth case was studded with small yellowish spots, from 
which, on section of the mucous membrane covering them, a drop 
of purulent-looking fluid exuded. The lining membrane of the 
larynx in the same subject was dusky red, the chordae vocales 
and arytaeno-epiglottidean folds distinctly thickened from effusion 
of serosity into the submucous cellular tissue." 1 

Sec. III. — Heart and Blood. The heart was found in some 
of Dr. Gerhard's cases softened, flabby, and easily broken down ; 
in others, it was in its usual condition. 

The appearance of the blood, contained in the heart and in 
the large vessels, was striking and peculiar. It was of a very 
dark color, often almost black, thick in its consistence, and some- 
times oleaginous. In one case, the blood in the cavities of the 
heart, in the aorta, the vena cava ascendens, and in the femoral 
vein, is described as being like molasses, in color and consistence, 
with minute fatty globules floating in it. 

The substance of the heart, in Dr. Shattuck's cases, was not 
altered. In the right ventricle, there were from one to three 
ounces of black, liquid blood; and in three cases, a somewhat 
smaller quantity in the left. 

1 Jenner, &c. p. 50. 



230 TYPHUS FEVER. 

In all Dr. Reid's cases, the blood appeared to be in a fluid 
state, or nearly so, in the large veins ; but in several, a greater 
or less number of coagula, generally small and soft, were found 
in the right side of the heart. In two subjects the blood, in the 
same situation, was in a grumous state. 

Of twenty-nine cases, Dr. Jenner found the heart flabby in 
fifteen, and firm in fourteen. In twelve cases, the lining mem- 
brane was stained of a dusky-red color. The staining of the en- 
docardium, and the flabby condition of the heart were generally 
found together; and they were frequent in proportion to the 
length of time that had elapsed after death, before the bodies 
were examined. 1 

"The fluid condition of the blood generally," says Dr. Jenner, 
" was observed in about equal proportions in the subjects dead 
from typhoid and typhus fevers ; but with this exception, there was 
a marked difference in the blood in the two diseases ; it was far 
more profoundly diseased, i. e. it deviated far more from its 
healthy condition, in the cases of typhus than in those of typhoid 
fever." 2 



ARTICLE II. 

LESIONS OF THE BRAIN. 

In all the cases reported by Dr. Gerhard, there was unusual 
engorgement of the sinuses and the larger vessels of the brain. 
These were filled with dark-colored fluid blood, in some cases, 
in the large sinuses, surrounding a soft, greenish coagulum. In- 
flammatory injection of the pia mater is not mentioned. Varying 
quantities of serum, from one or two drachms to one or two 
ounces, were found, in a certain proportion of cases, under the 
arachnoid, or withhV the ventricles. The medullary portion of the 
brain was frequently of a violet tinge ; otherwise, the substance of 
the organ was unaltered. In Dr. Shattuck's cases, observed at 
the London Fever Hospital, the organs in the cranial cavity pre- 
sented no remarkable lesions. In three of them, there was slight 
sub-arachnoid infiltration. Of forty-three cases in which the 
brain was examined by Dr. Reid, in 1838 and 1839, there was 

' Jenner, &c, pp. 80-82. 2 Ibid. p. 84. 



LESIONS. — BRAIN. 231 

increased effusion of serum in twenty-five. This effusion, in a 
majority of instances, was situated between the arachnoid and 
the pia mater, and was commonly moderate in quantity, in many 
cases elevating the arachnoid above the surface of the convolu- 
tions only at the depending portions of the brain. Nearly all 
these patients exhibited more or less prominent cerebral symp- 
toms ; such as delirium, coma, subsultus tendinum, &c. ; but 
these symptoms were as frequently present, and as strongly 
marked, in the class of cases where there was no increased effu- 
sion of scrum as in the others. Of course, it is impossible to 
attribute the cerebral symptoms to the serous effusion. In every 
case but one, the bloodvessels of the brain are said to have been 
"well filled," and their congested condition was indicated by the 
number of bloody spots which appeared upon the cut surfaces of 
the organ, although these may have depended in part upon the 
fluidity of the blood. 1 Dr. Reid examined the brain in eighty- 
two additional cases of continued fever, between the years 1839 
and 1841, and the general results corresponded very nearly with 
those just stated. 2 

In five of thirty-nine cases examined by Dr. Jenner, coagula 
of various sizes were found within the cavity of the arachnoid. 
"In every case the coagulum was in the form of a delicate red 
film, varying in thickness, and consequently in hue, in different 
cases and in different parts of the same clot. It was almost 
colorless where thinnest, bright red where a little thicker, and 
deep purple at the thickest parts. It was in every case situated 
on the convex surface of the brain, and in one stretched from the 
anterior lobe to the tentorium, and from the median fissure to a 
point corresponding to a line drawn transversely, just above the 
external auditory foramen. In one case it consisted of two or 
three delicate fibrinous films only. When the dura mater was 
reflected, part of the clot adhered to the layer of arachnoid 
covering the pia mater. In three of the five cases the clot was 
double, i. e. existed on both hemispheres of the brain. In two 
cases it was confined to the right side. In one of the five it was 
accompanied by effusion of blood into the substance of the rectus 
abdominis. The substance of the brain was firm in four of the 
five, and apparently healthy in all. The vessels of the cerebral 

1 Ediu. Med. and Surg. Jouru., Oct. 1839. 2 Ibid., Aug. 1842. 



232 TYPHUS FEVER. 

substance and its meninges were not particularly congested ; the 
blood in the vessels of the pia mater fluid, but unable to be 
pressed out of them into the cavity of the arachnoid. No aper- 
ture could be found from which the blood had escaped — the sinuses 
were perfectly healthy ; the sources of the hemorrhage could not, 
consequently, be discovered." 1 

ARTICLE III. 

LESIONS OF THE ABDOMINAL ORGANS. 

Sec. I. — Stomach. The mucous membrane of the stomach 
was more or less altered in all the cases reported by Dr. Gerhard. 
The most constant change consisted in softening of the membrane 
in the cardiac extremity, or grand cul-de-sac. This softening 
was sometimes confined to a small portion of the membrane ; 
sometimes it was quite extensive. It varied in degree, from a 
moderate diminution of the consistence of the membrane to its 
pulpy disorganization. In some instances the softening extended 
to the other coats of the stomach. Mamellonation of the mucous 
membrane, especially towards the pyloric extremity, was not 
uncommon. In some cases there was blue engorgement of the 
large veins ; in some a pointed redness, and in others a continu- 
ous dull slate color of the mucous coat. 

Dr. Jenner found the mucous membrane of the stomach pale, 
or healthy in color, in twenty-three of thirty-seven cases. It 
was of a uniform dusky gray hue in two cases. There was some 
redness, or minute hemorrhagic spots in a small number of cases. 
In one case there was recent ulceration. Mamellonation was 
noted in fourteen cases. The consistence of the mucous mem- 
brane was normal, or nearly so, in twenty-two cases. In four 
cases there was extreme softening of the great cul-de-sac, so that 
it ruptured in the removal, or in the washing of the organ. 

Sec. II. — Intestines. The intestinal canal in all its tissues, and 
throughout its entire extent, was very constantly and remarkably 
free from disease in all Dr. Gerhard's cases. In the reported 
cases no appreciable lesion is mentioned, excepting occasional 
spots or patches of ecchymosis. The examinations were tho- 

1 Jenner, &c. p. 47. 



LESIONS. — ABDOMINAL ORGANS. 233 

roughly made, and especial solicitude was felt, and corresponding 
carefulness was taken, to ascertain accurately the state of the 
small intestine, and its elliptical plates. Amongst the entire num- 
ber of autopsies there was but a single case, and that of doubtful 
diagnosis, in which there ivas the slightest deviation from the natu- 
ral appearance of the glands of Peyer. " In the case alluded to, 
in which there had been some diarrhoea, the agglomerated glands 
of the small intestine were reddened, and a little thickened ; but 
there was no ulceration, and no thickening or deposit of yellow 
puriform matter, in the submucous tissue. The disease of the 
glands resembled that sometimes met with in smallpox, scarlet 
fever, or measles, rather than the specific lesion of dothinenteritis. 

" In all other cases, the glands of Peyer were remarkably 
healthy in this disease, as was the surrounding mucous mem- 
brane, which was much more free from vascular injection than it 
is in cases of various diseases not originally affecting the small 
intestine. 

" The mesenteric glands were always found of the normal size, 
varying, as in health, from the size of a small grain of maize to 
three or four times these dimensions. With the exception of a 
slightly livid tint, common to them and the rest of the tissues, 
they offered nothing peculiar either in consistence or color. 

" The spleen was of the normal aspect in one-half the cases ; in 
the other half, it was softened, but not enlarged, and in one case 
out of five or six enlarged and softened. 

"Thus, the triple lesion of the glands of Peyer, mesenteric 
glands, and spleen, constituting the anatomical characteristic of 
the dothinenteritis, or typhoid fever, although sought for with 
the greatest care, evidently did not exist in the epidemic typhus. 
Indeed, it was a subject of remark that, in the typhus fever, the 
intestines were more free from lesion than in any other disease 
accompanied by a febrile movement. This exemption extended 
to the large intestine, until the summer heats began, when a few 
scattering cases offered some symptoms of diarrhoea, during the 
prevalence of an epidemic dysentery ; and, where they terminated 
fatally, softening and other signs of inflammation of the mucous 
coat of the colon were observed." 1 

The liver was found sometimes moderately softened ; some- 
times engorged with dark, fluid, oily blood, and sometimes spotted 

1 Am. Journ. of Med. Sci., Feb. 1837. 



234 TYPHUS FEVER. 

with ecchymosis. In many cases, however, it was the seat of no 
appreciable lesion. The contents of the gall-bladder differed in 
different cases : in some the bile was viscid ; in some it was thick, 
dark, grumous, and so on ; in others it was healthy. The kid- 
neys, in some instances, were of a darker color than natural, but 
commonly they were free from disease. 

It is hardly necessary to give in detail Dr. Jenner's account 
of the condition of the bowels. With three exceptions, Peyer's 
glands were perfectly healthy, i. e. neither elevated, reddened, 
softened, nor ulcerated. The exceptional cases did not present 
the lesions of typhoid fever. With two exceptions, occurring in 
tuberculous children, the mesenteric glands were entirely free 
from disease. 

Dr. Jenner found the average weight of the spleen in thirty- 
four subjects, aged more than fifteen years, and who died before 
the termination of the fourth week of the disease, to be seven 
ounces and five drachms. 

In Dr. Shattuck's cases, the small intestine was generally 
healthy. The thickness and consistence of the mucous mem- 
brane were natural, and there was no lesion whatever of Peyer's 
patches or of the mesenteric glands. In three of four cases 
there was either redness or softening of the mucous membrane 
of the upper portion of the large intestine. In all the cases, the 
fecal matter contained in the large intestine was small in quantity, 
pultaceous, soft, and yellowish. In two cases the mucous mem- 
brane of the stomach was unaltered ; in two others it was red- 
dened, softened, or mamellonated. There was no constant lesion 
in the other abdominal organs. 1 Of twenty-one cases examined 
by Dr. Stewart, at the Glasgow Infirmary, the aggregated fol- 
licles were distinctly elevated in two; very slightly so in eight, 
not elevated in five, and scarcely visible in six. In none of them 
was there any ulceration. Of thirty-three cases examined by 
Dr. Reid, in 1838 and 1839, in the Edinburgh Infirmary, only 
two presented the follicular lesion of typhoid fever, and even 
these doubtfully. These had been protracted cases, and came 
from the country. Of the remaining thirty-one cases, Peyer's 
glands were distinctly elevated in four ; visible, but not elevated, 
in nine ; scarcely visible in seven ; and not visible in eleven. In 

1 Med. Exam., vol. iii. p. 150. 



LESIONS. — ABDOMINAL ORGANS. 235 

none were they ulcerated. 1 Between the years 1839 and 1841, 
Dr. Reid examined the intestines in ninety-one cases of continued 
fever. The result is very remarkable, and corresponds in a very 
striking manner with that of his previous investigations. The 
elliptical patches and solitary glands were found in the following 
conditions, to wit : not visible to the naked eye in six cases, 
scarcely visible in seventeen, distinct but not defined in four, de- 
fined in eight, neither reddened nor elevated in forty-four, ele- 
vated but not ulcerated in six, elevated and ulcerated in six. In 
all these last cases the mesenteric glands were enlarged and more 
or less softened. In two of them, there was perforation of the 
ileum, producing rapid and fatal peritonitis. Five of these cases 
occurred in laborers on the Glasgow railroad ; and they had been 
for a short time previous to their illness located in Linlithgow or 
its neighborhood, about seventeen miles west from Edinburgh. 
Their average age was twenty -five years ; the youngest was 
eighteen and the oldest thirty-five. Dr. Reid says : " During 
the whole three years and a half that I conducted the post-mortem 
examinations in the Edinburgh Infirmary, in no single case did 
I observe, in any individual who had been seized with fever 
while residing in Edinburgh, anything resembling the changes 
described as occurring in the lower part of the ilium in the 
typhoid fever of Paris." 2 

"Whether or not," adds Dr. Reid, "the typhoid and typhus 
fever be identical or different diseases, we shall not venture at 
present to give an opinion ; but if it should turn out that they are 
specifically the same disease, it would prove an interesting subject 
of inquiry to endeavor to ascertain why the typhoid fever should, 
for several years past, never be found in Edinburgh, while it ex- 
isted at Linlithgow, Anstruther, and other places in Fifeshire." 
An interesting subject, indeed ! And is the inquiry any less in- 
teresting why, if the diseases are specifically the same, one of 
them, with no constant lesion of the solids, should be the common 
disease of Scotland and Ireland, and the other, ivith a profound 
and peculiar anatomical lesion, should be almost the sole con- 
tinued fever of France and of the United States of America ? 
Is there any other disease that exhibits such a character ? The 

1 Ed. Med. and Surg. Journ., Oct. 1839. a Edin. Med. Journ.. Aug. 1842. 



236 TYPHUS FEVER. 

Register of Dissections at the same Institution, kept by Dr. John 
Home, from 1833 to 1837, showed that, of one hundred and one 
cases, only seven presented ulcerations of the elliptical plates. 
In two there was perforation. These were probably instances of 
typhoid fever. Thickening, mamellonation, and other lesions of 
the mucous membrane of the stomach, were found in about' one- 
fourth of the cases. The spleen was generally larger than usual, 
soft, and in some cases almost diffluent. In one instance this 
organ weighed eleven, and in another fourteen, ounces. 

Sec. III. — Miscellaneous. The petechial eruption frequently 
continues visible after death. In three of four cases examined 
by Dr. Shattuck, the spots penetrated the thickness of the skin 
to the subcutaneous cellular tissue, and communicated to the 
parts they occupied a purplish color. 

Amongst the pathological phenomena of typhus fever, may be 
mentioned the tendency which manifests itself, in a certain pro- 
portion of cases, to early and rapid decomposition. Dr. Pickels, 
in his Report on the Typhus Fever at Cork, says that this tend- 
ency was shown by the rapid putrefaction of bodies after death, 
rendering necessary their almost immediate interment. In many 
instances the skin of the arms, thighs, and of almost the entire 
body, changed to a deep livid or black color, somewhat of the 
appearance as if scorched by gunpowder, several hours before 
death. 1 Dr. Gerhard noticed that rapid putrefaction took place, 
especially in the bodies of those patients from whom the offensive 
ammoniacal odor, already spoken of, had been most strongly per- 
ceived during life. 

Dr. Jenner noticed that, in subjects examined within twenty- 
four hours after death, cadaveric rigidity was found much less 
constantly in cases of typhus than in those of typhoid fever. 2 

Sec. IV. — General Remarks. The most striking fact in the 
pathological anatomy of typhus fever consists in the absence of 
any constant and characteristic lesion. One of the most uniform 
and probably one of the most important alterations is that of the 
blood. It seems to me, in the present state of our knowledge, 

1 Trans, of Phys. of Ireland, \ol. iii. p. 202. 

2 Jenner, &c. p. 40.- 



LESIONS. — ABDOMINAL ORGANS. 237 

quite idle and useless to attempt to trace any obvious connection 
between the symptoms and the lesions, or, in other words, to refer 
the former to the latter. The broad and fundamental difference 
in the state of Peyer's glands, and the mesenteric glands, in ty- 
phus and typhoid fever, will, of course, be noticed. 



238 



CHAPTER IV. 

CAUSES. 

I SHALL enumerate under this head some of the principal cir- 
cumstances which appear to favor the occurrence and spread of 
typhus fever. Our knowledge of its efficient causes, excepting 
that of contagion, is very limited and imperfect. 

Sec. I. — Locality. It is very evident that the geographical 
boundaries within which typhus fever prevails, as a common and 
more or less constant disease, are much less extensive than those 
of typhoid fever. The actual extent to which typhus fever has 
heretofore prevailed in different regions and countries, owing to 
the imperfect histories which have been left to us of this and of 
analogous diseases, and the consequent doubtfulness and uncer- 
tainty of our diagnosis, is a matter which it is now impossible to 
determine with any considerable degree of precision. One thing 
is very certain, and that is, that typhus fever has always been of 
very rare occurrence in New England. Nathan Smith, one of 
the great observers of New England diseases, says expressly, 
that he never met with any other form of continued fever than 
that which he has so well described under the then common 
name of typhus fever, and which was evidently the typhoid fever 
of this work. Very few of the New England country physi- 
cians now living, I presume, have had an opportunity of seeing 
typhus fever on their own soil ; excepting now and then a few 
instances, in cases of foreigners recently arrived from Britain. 

A continued fever, which seems to have been evidently conta- 
gious, prevailed in the Boston Almshouse in 1817. The account 
of it, however, which was published in the New England Journal 
of Medicine and Surgery, for April, 1818, by Dr. John P. 
Brown, is not sufficiently detailed and particular to enable us to 
decide whether it was typhus or typhoid fever. Many cases are 
annually received into the hospitals of our large cities, especially 



CAUSES. — LOCALITY. 239 

those of New York, from the British emigrant vessels. The 
ship Eutaw arrived at New York March 6, 1842, forty-two days 
from Liverpool, with about two hundred passengers, mostly Irish, 
seventy of whom were sick with typhus on her arrival. Amongst 
these there were eight deaths. The bark Barlow arrived at New 
York from Greenock, May 15, 1842, after a passage of forty 
days, with nearly fifty typhus patients ; there having been three 
deaths before her arrival. These are instances of what occurs 
nearly every year. 1 In August, 1840, twenty-one cases of typhus 
were admitted, from a single vessel, into the Boston Almshouse. 
Four of the cases were fatal. Dr. Butler informs me that the 
dulness of the mind, deafness, stupor, suffusion of the eyes, and 
dinginess of the skin, were amongst the most prominent symp- 
toms. The bowels were usually torpid, and there was slight 
metcorism in only two or three cases. Dr. Doane, physician at 
the New York quarantine establishment, informs me that, amongst 
the most striking and constant phenomena of the disease, he has 
noticed the injection of the eyes, the fuliginous aspect of the 
skin and deafness. Diarrhoea is rare, and the alvine discharges, 
when procured by medicine, arc dark colored and offensive. The 
evidences of the contagious character of the disease observed by 
Dr. Doane are very positive ; during his connection witli the 
institution, a period of about three years, no less than fifteen or 
sixteen individuals connected with the hospital having died with 
typhus fever, which had been contracted from the emigrant pa- 
tients. 

The disease which was commonly called spotted fever, and 
which prevailed in many parts of New England, principally be- 
tween the years 1807 and 1816, is supposed by some writers to 
have been the true typhus fever. Dr. Gerhard says that it was 
similar in its nature to the British typhus. Dr. James Jackson 
thinks that it was a different disease. It is very certain that, in 
many important particulars, it bore a very striking resemblance 
to true typhus. This resemblance is noticed by most writers 
upon the disease. Dr. Elisha North called it a new petechial 
malignant typhus. Dr. Hale, of Boston, whose description of 

1 The number of these cases during the present year, 1847, has been immensely 
greater than it ever was before. The hospitals of most of the commercial cities 
from the St. Lawrence to New Orleans have been crowded with typhus patients, 
coming mostly in emigrant ships from Scotland, England, and Ireland. 



240 TYPHUS FEVER. 

the disease, as it prevailed at Gardiner, Maine, in the spring of 
1814, is the fullest and best that has been published, regards it 
as a congestive fever. He speaks of the many points of resem- 
blance which exist between it and Dr. Armstrong's typhus ; but 
he says, also, that there are many strong points of difference be- 
tween the two diseases. It is not easy at the present day, upon 
such evidence as we possess, to decide with any confidence upon 
the precise character of the spotted fever of New England. 
Without going any farther into the consideration of this question 
here, I will merely observe that an examination of most of the 
records that have been left us of this disease has induced me to 
believe that it belongs to that class of new and more or less tem- 
porary epidemics, each having its peculiar character, marked by 
its peculiar phenomena, and depending upon new and peculiar 
combinations of unknown morbific influences — which have always 
from time to time made their appearance, rather than to the 
class of established and permanent maladies. 

Dr. Gerhard thinks that some of the epidemics which overran 
the Middle States, between the years 1812 and 1820, were of 
typhus fever ; and that it was of this disease that three distin- 
guished professors in the University of Pennsylvania — Rush, 
Wistar, and Dorsey — died. He says that Dr. Parrish, one of the 
most experienced physicians of Philadelphia, who practised very 
extensively amongst all classes of inhabitants in the winter of 
1812-13, when he saw some of the cases at the Philadelphia 
Hospital, in 1836, immediately recognized their identity with 
those of the former epidemic. A pupil of Dr. Gerhard's, from 
North Carolina, informed him that he had witnessed a similar 
fever amongst the negroes. It seemed to be contagious, and 
from the absolute disregard of cleanliness and the crowded state 
of the negro cabins, it frequently spread extensively. It is 
hardly necessary to say that these and similar opinions are to be 
received with a good deal of caution ; and that the extent and 
frequency of the prevalence of true typhus fever in the United 
States can only be determined by the accurate and continued ob- 
servations of the future. Upon this question, as upon so many 
others connected with epidemic disease, the past sheds but a con- 
fused and uncertain light. 

It is very clear that, for the last thirty years, at least, true 
typhus fever has been almost or entirely unknown in France. In 



CAUSES. — SEASON, WEATHER, ETC. 241 

the years 1813 and 1814, there appeared at Paris a severe epi- 
demic fever, which was first noticed amongst the troops who re- 
turned from Napoleon's campaigns in Germany, and the east of 
France ; and which afterwards spread amongst the inhabitants of 
Paris, and other large cities, and was everywhere extremely fatal. 
This epidemic, Dr. Gerhard is disposed to believe was typhus 
fever ; although Louis, Chomel, and other French physicians who 
observed it, are inclined to regard it as identical with their pre- 
vailing typhoid fever, or dothinenteritis. 

A writer in the October number of the British and Foreign 
Medical Review, for 1841, thinks that the fever which devastated 
Italy in 1816 and 1817 was identical with the typhus of Great 
Britain. 

The fixed and constant residence of typhus fever is to be found 
in the British Islands. The mud cabins of Ireland, and the damp 
dark cellars of the cities of Great Britian, are its true habitat. 
These are its perpetual lurking-places, and here it is always to 
be found. The terms Irish typhus and British typhus have, 
indeed, come to be its most distinctive appellations. 

The number of deaths in England, except the metropolis, from 
typhus, in 1841, was 18,795; of these, 6,618 were males, and 
7,077 females. The number in 1842, was 15,027 ; of these, 
7,056 were males, and 7,971 females. 1 

According to the Report of the Registrar-General, there is no 
marked difference in the mortality from typhus in town and coun- 
try districts in England ; the annual mortality to one million 
living, in 1841, being for the town districts, 908; and for the 
country districts, 929. 

Dr. John Hunter says he never met with the disease in the West 
Indies. 2 

Sec. II. — Season, Weather, $c. Typhus fever prevails at all 
seasons of the year. Several of the Irish writers have remarked, 
in general terms, that the disease is found to prevail most exten- 
sively during the early part of summer. It seems probable, 
however, from extensive and accurate researches, that the differ- 
ence in the extent to which the disease prevails in the different 
seasons of the year is not very great. Illustrative of this point, 

' Rep. Reg. Gen. 2 Hunter's Diseases of the Army, p. 83. 

16 



242 TYPHUS FEVER. 

so far as a single locality is concerned, I copy the following table 
from Dr. Mateer's statistics of fever, during a period of eighteen 
years at the Belfast Fever Hospital. It shows the aggregate 
number of admissions into the hospital, arranged according to the 
four seasons, for this long and continuous series of years, with the 
average rate of mortality for the several seasons. 



Summer 


2596 


1 to 17|| for Summer. 


Autumn 


2482 


1 to 15^J for Autumn. 


Winter 


2359 


1 to 14^4 for Winter. 


Spring 


2412 


1 to 13f i for Spring. 



It appears from this table that the influence of season, in favor- 
ing the prevalence of typhus fever, is small. It appears, also, 
that the rate of mortality is highest in the spring and winter. 1 

The deaths from typhus in England, in 1841, were distributed 
in the following manner through the quarterly periods of the year : 
in spring, 4218 ; in summer, 3498 ; in autumn, 3197 ; in winter, 
3941. 2 In the following year, 1842, there was a wider difference ; 
the deaths in spring, being 3910 ; in summer, 3480 ; in autumn, 
3680 ; and in winter, 5131. 3 

As to the effects of the sensible qualities and changes of the 
weather, nothing very positive seems to have been ascertained. 
These effects are doubted by some observers, and not agreed upon 
by others, who admit their existence. Thus Dr. Percival says : 
" It has long been observed that protracted dry weather is pecu- 
liarly productive of fever in Dublin;" and Dr. Cheyne says: 
" More than thirty years ago, it was remarked by a very eminent 
physician, the late Dr. Quin, that wet and cold summers always 
proved healthy ones in Dublin." Still, the same excellent ob- 
server informs us that the summers of 1816 and 1817, when 
fever was extensively prevalent, were wet, cloudy, and cold ; and 
Dr. Barker makes the following remark: "The state of the 
weather, as to moisture, has been said to have affected the pro- 
gress of this fever in other parts of Ireland. I cannot say that I 
have observed this in Dublin, although I have kept a register of 
the weather during several years past." 4 Dr. Henderson, in his 
account of the epidemic at Edinburgh, in 1838 and 1839, says 

1 Dub. Journ. of Med. Sci., vol. x. p. 34. 2 Rep. Reg. Gen., 1843. 

3 Ibid., 1844. 4 Trans, of Phys. of Ireland, vol. ii. p. 527. 



CAUSES. CONTAGION. 24o" 

that cold weather had commonly the effect of increasing the num- 
ber of admissions into the Infirmary, which declined again when 
the temperature was moderate. 1 Dr. James Arrott, of Dundee, 
remarks that all his inquiries tend to prove that great vicissitudes 
of the weather, and especially that great degrees of cold and wet, 
are powerful causes of typhus. 2 The great epidemic of 1741 was 
coincident with two very severe winters and two very dry summers, 
one of which was very hot ; that of 1817 was attended by mild 
winters and very wet and cool summers. Rutty says : " When- 
ever we observe the usual harmony and proportion of the winds 
and attendant weather to vary much, we may expect an unhealthy 
season." 3 

Sec. III. — Contagion. Typhus fever has been almost univer- 
sally regarded, by those physicians who have enjoyed the beat and 
most extensive opportunities for observing it, as a disease capa- 
ble of direct transmission from one individual to another, by means 
of contagion. Amongst others of the older British writers who 
maintained this opinion, may be mentioned Willis, lluxliain, 
Grant, and Pringle ; and amongst the moderns, there are but few 
who dissent from it. Different observers differ, it is true, amongst 
themselves, in regard to the extent to which the principle of con- 
tagion operates in the propagation of the disease, and in regard 
to some other points connected with this subject, but they very 
generally admit the fundamental fact, of its contagious transmis- 
sibility. Dr. O'Brien, in a Dublin Fever Hospital Report, for 
1819, in allusion to this matter, says : " That the skepticism of 
one or two individuals has gone so far as to deny the existence of 
contagion altogether in the fevers of our climate, but that the 
opinion is so singular, and so contrary to the general sense of 
mankind, that deservedly little attention has been paid to it." 

The extreme doctrine in regard to the contagiousness of typhus 
fever is, that the disease is exclusively and invariably the product 
of contagion ; that it never arises from the action of other causes 
alone ; that it is never spontaneous, as it is called, in its origin; 
that it resembles in this respect smallpox, and not scarlatina. 
This opinion is not generally entertained, and must have been 

1 Edin. Med. and Surg. Journal, Oct. 1839. 2 ibid., vol. li. p. 127. 

3 Harty's Sketch, p. 142. 



244 TYPHUS FEVER. 

always the result rather of philosophizing than of observing ; for, 
certainly, the evidence of direct observation is altogether against 
this exclusive opinion. It is easy to see that the accurate settle- 
ment of a question of this character is exceedingly difficult, and 
that where a considerable number and variety of influences are 
or may be acting together in the production of disease, it must be 
often quite impossible to determine, with any degree of certainty, 
the actual and comparative agency of each. One thing, however, 
in regard to the present matter, is perfectly clear ; and that is, 
that, in very many cases, there is no positive evidence, whatever, 
of the action of contagion. Dr. Edward Percival says: "Hav- 
ing made it my business to inquire into the origin of most cases 
of fever that were admitted to the Hardwicke Hospital, during 
several years, I found the results to point less frequently and 
precisely to a contagious source than I should have anticipated." 1 
Dr. F. Barker observes that, of ninety patients in the Cork 
Street Fever Hospital, in October, 1817, of whom minute inquiry 
was made in relation to this point, only twenty-four could' refer 
their cases to the effects of contagion. 2 From a pretty careful 
and certainly an unprejudiced examination of this subject in the 
observations and opinions of British writers, I think we may look 
upon it as well settled, that the morbid actions constituting ty- 
phus fever are capable of generating in the body a poison, which, 
when concentrated, and aided in its operation by favoring cir- 
cumstances, will produce the same disease in persons exposed to 
its influence. We may consider it also as not less certain, that 
the same poison may be generated by other agencies, amongst 
the most active of which seem to be the crowding together in 
close, unventilated apartments, amidst accumulated personal 
filth, of the wretched and suffering poor. I shall state the more 
obvious grounds upon which these conclusions rest. 

Dr. O'Brien, in his Cork Street Fever Hospital Report for 
1816, states that, of nine physicians who had been permanently 
attached to the Institution, five had had the disease, in two of 
whom it proved fatal. Of the four who escaped, two had had 
contagious fever before their connection with the hospital. All 
the nurses employed in the hospital had suffered from the dis- 

i Trans, of Phys. of Ireland, vol. i. p. 287. 2 Ibid., vol. ii. p. 530. 



CAUSES. — CONTAGION. 245 

ease. 1 Of the medical men connected with the South Fever 
Asylum, at Cork, during the epidemic of 1817, 1818, and 1819, 
seven physicians, the apothecary, and his apprentices, contracted 
severe fevers. Two of the physicians died. Nearly all the other 
persons connected with the hospital, and who, from the nature 
of their occupations, were in frequent and close communication 
with the sick — the hair-cutter, the porters, the nurses — were 
attacked with the fever. 2 At the Hardwicke Fever Hospital, 
Dublin, in 1816, all the nurses and other residents in the hospital, 
amounting to twenty-three persons, escaped the disease. Dr. 
Cheyne attributes this exemption to the cleanliness and free ven- 
tilation of the Institution. 3 Still, it appears that, in the follow- 
ing year, many of the officers of the same establishment caught 
the fever. Amongst them were eight or nine medical gentlemen, 
the steward, all the servants, in succession, whose business it was 
to remove the clothes of the patients upon their first admission, 
and most of the unseasoned nurses. 4 

The opinions of the celebrated Dr. Armstrong, upon this point 
in the history of typhus, are well known. In the early part of 
his life he adopted the popular doctrine of the contagious nature 
of the disease. In a paper on the origin, nature, and prevention 
of typhus fever, communicated to the Medical Intelligencer in 
May 1822, he expresses some doubts as to the correctness of his 
former opinions in relation to this question. His skepticism in 
regard to the contagious character of typhus, under any circum- 
stances, continued to increase with his advancing years and ex- 
perience ; and in a lecture on the disease, published in 1825, 
although he does not deny the possibility of the transmission of 
typhus by contagion, he is unwilling to admit the existence of 
any positive evidence that such is ever the case. It ought, how- 
ever, to be stated here, that Dr. Armstrong's conclusions upon 
this subject were evidently somewhat influenced by his singular 
doctrine of the essential identity of intermittent, remittent, and 
typhus fevers, and of their dependence upon a single common 
cause. 5 

It may be added in connection with this subject, that nothing 

• Trans, of Phys. of Ireland, vol. ii. p. 485. 2 Ibid., vol. iii. p. 224. 

3 Dublin Hosp. Reports, vol. i. p. 55. ' * Ibid., vol. ii. p. 53. 

6 Memoir of the Life and Medical Opinions of John Armstrong, by Francis 
Boott, vol. i. pp. 149-171. 



246 TYPHUS FEVER. 

is more common, during the prevalence of typhus fever, than for 
a considerable number of individuals residing in the same room 
to be successively attacked with the disease. In many instances 
all the members of a large family, and even of several families, 
inhabitants of the same house, have, one after another, become 
its subjects. This common occurrence is noticed by most of the 
Irish writers upon fever. Of 9588 patients received into the 
Belfast Fever -Hospital, from 1818 to 1835, 2342 came in single 
cases, while 7246 came in numbers of two or more from the same 
family. They came from 1856 families, thus giving an average 
of nearly four patients to a family. 1 One of the circumstances 
which early attracted the attention of Dr. Gerhard in the Phila- 
delphia typhus of 1836, was the fact that the patients came in 
groups, and several from the same house. Amongst the first 
admitted into the hospital were seven negroes, the entire popula- 
tion of a cellar, in the lower part of the city. This occurrence 
of several cases in the same house has been but very rarely 
observed amongst the comfortable and rich classes in Ireland. 
Under these circumstances, the fever has not usually extended 
to more than a single member of a family. 

The latent period of the contagious principle has not been 
accurately ascertained. It is probably different in different cases. 
Dr. Barker says that, in many instances, it seems to extend to 
two or three weeks. Dr. Perry of Glasgow, intimates incidentally, 
in his letter on typhus fever, published in the Dublin Journal of 
Medical Science, for January, 1837, that the disease rarely if ever 
makes its attack in less than eight days from the time of exposure. 
The same gentleman says that numerous observations and experi- 
ments have satisfied him that typhus fever does not communicate 
its contagious principle before the ninth day of the disease, and 
perhaps not till a later period. Many very striking instances 
are recorded, however, by different writers, in which the disease 
seems to have been directly and immediately received from a 
patient laboring under it, and to have instantaneously manifested 
itself. Dr. Henry Marsh, of Dublin, in an admirable paper upon 
the origin and latent period of fever, published in volume IV. of 
the Dublin Hospital Keports, enumerates twenty cases of this sort. 
He says that they constitute a few amongst many facts of the 

1 Dub. Journ. of Med. Sci., vol. x. p. 35. 



CAUSES. — CONTAGION. 247 

same kind, which he has been able to collect, and that every day's 
observation adds to their number. In most of these instances, 
the persons, many of whom were nurses or physicians, while in 
the act of rendering some service to the sick, which exposed them 
to the strong, offensive odor arising from the beds or bodies of 
the patients, were immediately seized with headache, great pros- 
tration of strength, and with nausea, perhaps, or rigors; and these 
symptoms were soon followed by the full development of the dis- 
ease, in many of which cases it proved fatal. He mentions the 
deaths of three physicians, Dr. Crawford, Dr. James Clarke, and 
Dr. Waring, under such circumstances. Two cases of a similar 
kind are reported by Dr. Gerhard, in his account of the Phila- 
delphia typhus of 1836. He says: "The nurse was shaving a 
man, who died in a few hours after his entrance; he inhaled his 
breath, which had a nauseous taste, and in an hour afterwards 
was taken with nausea, cephalalgia, and ringing in the ears. 
From that moment the attack of fever began, and assumed ■ 
severe character. The assistant was supporting another patient 
who died soon afterwards ; he felt the pungent sweat upon hifl 
skin, and was taken immediately with the symptoms of typhus.' 1 
It would be easy to multiply, and that to a great extent, similar 
examples. Sir John Pringle says of the jail fever: " I have ob- 
served some instances of a high degree of contagion attending it; 
but the common course of the infection is slow, and catching to 
those chiefly who are constantly confined to the bad air, such as 
the sick in hospitals, and their nurses, and prisoners in jails." 1 

In connection with this subject it should be stated that, even 
during the prevalence of very general epidemics, certain circum- 
scribed localities sometimes are nearly or quite exempt from the 
disease. Thus, in the House of Industry at Cork, and in the 
Foundling Hospital of that city, in 1817, 1818, and 1819, the 
disease scarcely showed itself, when very prevalent amongst the 
inhabitants in general. The jail at Cork also remained free at 
the same time ; and in the Marine School, and the Royal Hiber- 
nia Military School, in Dublin, there were but few cases. 2 The 
occasional exemption of the inmates of these and similar institu- 
tions has been generally attributed to their seclusion, and con- 
sequent freedom from exposure to contagion. 

1 Dis. of Army, p. 256. 2 Account, etc. By Barker and Cheyne, vol. i. p. 96. 



248 TYPHUS FEVER. 

Another important quality of the contagious poison seems to 
be very well ascertained, to wit, that, as a general rule, it must 
be concentrated and abundant, so to speak, in order to excite the 
disease. A few cases in a large, cleanly, and well- ventilated 
ward, do not often communicate the disease to the other occu- 
pants, nor to the medical attendants and nurses. Dr. Christison's 
testimony on this point is very explicit and direct. He says : 
" The infection of continued fever is for the most part by no 
means virulent. This is contrary to universal prejudice among 
unprofessional persons, and to the opinion entertained even by 
some members of the medical profession. But it is nevertheless 
certain, so far as minute observations of several violent epidemics 
during the last twenty years can determine the point, that mod- 
erate precautions will render the infectious atmosphere inert. 
Cleanliness and ventilation will speedily extinguish any epidemic. 
For it is well ascertained that fever, communicated to an indi- 
vidual in the better ranks by attendance on the sick in hospital, 
is very rarely propagated in his own station, or to any of his 
attendants. Among numerous instances known to the writer, 
of young practitioners and medical students who have caught 
fever in the prosecution of their practical studies, not a single 
case has occurred where the disease was communicated in their 
families at home or in their lodging-houses." 1 

Sec. IV. — Epidemic. The entire history of typhus fever 
shows, conclusively, that it is often very intimately dependent 
upon that unknown influence, or combination of influences, to 
which the term epidemic has been applied. After estimating, as 
nicely as our means will enable us to do, the agency of the se- 
veral supposed causes, exciting and predisposing, of the disease, 
we are still unable to account for its general prevalence, during 
certain periods, and over more or less extensive regions, without 

1 Tweedie's Library of Practical Medicine. I cannot refrain from asking here, 
in a note, how far this dependence of fever upon a want of cleanliness and ven- 
tilation is applicable to typhoid fever ? Do my friends who believe in the essential 
identity of these two diseases, and who are familiar with the continued fever of 
this country, believe that any cleanliness and any ventilation will arrest the latter 
disease ? Let them try it, when typhoid fever prevails as it so often and so ex- 
tensively does during the beautiful and breezy Indian summer, amongst the most 
cleanly, the most temperate, the best clad, the best fed, and the best sheltered 
people that this world has ever seen — the rural population of the Eastern States. 



CAUSES. — CROWDING, FILTH, FAMINE, ETC. 249 

resorting to this ancient hypothesis of an occult influence, or 
agent, coming, we know not whence — whether from the earth, 
the air, or the stars — and acting, we know not how, in the pro- 
duction of its results. In the case of typhus fever, as of many 
other diseases — of scarlatina, of measles, of smallpox — it is evi- 
dent that, independent of all the circumstances which are ad- 
mitted to favor its occurrence and its extension, there exists at 
certain times a predisposition or tendency to the disease which 
we are wholly unable to account for, or explain. Like the small- 
pox, and like scarlet fever, it is always present in Ireland ; but 
at considerable intervals, we find it increasing immensely in the 
extent of its prevalence, and after the lapse, usually, of from one 
to two or three years, again subsiding to its permanent and aver- 
age standard. Several of the great Irish epidemics have been 
already frequently alluded to. Barker and Cheyne are inclined 
to think that the plagues, as they were called, which accompanied 
the two great civil wars in Ireland — the first in Queen Elizabeth's 
time, and the second, that which commenced in 1641 — were epi- 
demics of typhus. There are subsequent histories of epidemics, 
more or less complete, in 1708 and 1709 ; in 1718, 1719, 1720, 
and 1721 ; from 1728 to 1731 ; in 1740 and 1741 ; in 1762 : 
from 1797 to 1802 ; in 1817, 1818, and 1819, and so on. 

Barker and Cheyne estimate the number of cases during the 
epidemic of 1817, 1818, and 1819, at one million and a half. 

It is remarked by Barker and Cheyne, that the duration of epi- 
demics has in many instances been about two years. This was 
the case in 1740 and 1741 ; in 1800 and 1801 ; and in 1817, 
1818, and 1819. 1 

Sec. V. — Crowding ; Filth; Famine, etc. Amongst the cir- 
cumstances which, to say the least of them, are very frequently 
associated with the presence of typhus fever, are the crowding of 
persons together in dark, damp, and badly-ventilated apartments; 
anxiety ; fatigue ; excesses ; exposure to the inclemencies of the 
weather, and scanty and poor food. The real and relative agency 
of these several influences, in the production of the disease, has 
not been very minutely and carefully studied, but there can be 
little doubt that they are often amongst its most powerful and 
prolific causes. 

1 Account, etc., vol. i. p. 133. 



250 TYPHUS FEVER. 

The very intimate connection of typhus fever with crowded, 
ill-ventilated, and filthy apartments, has been universally admitted. 
This is the pestilence which dogs the footsteps of retreating and 
discomfited armies, and takes up its dwelling in their tents; 
which hides itself within the dark and noisome walls of ancient 
prisons ; which lurks amidst destitution and vice, in the narrow 
lanes and unlighted cellars of great cities, and which has been, 
for many generations, the perpetual inmate of the low mud-cabins 
of the Irish poor. 

Of jail fever, Sir John Pringle observes: "This disorder is 
incident to every place ill-aired and kept dirty ; that is, filled 
with animal steams from foul or diseased bodies. And upon this 
account, jails and military hospitals are most exposed to this kind 
of pestilential infection ; as the first are in a constant state of 
filth and impurity, and the latter are so much filled with the 
poisonous effluvia of sores, mortifications, dysenteric and other 
putrid excrements. I have seen instances of its beginning in a 
ward, when there was no other cause but one of the men having 
a mortified limb." 1 

The connection of the great typhus epidemics of Ireland with 
a general scarcity of food has long been noticed. It has been 
estimated that, during the years 1740 and 1741, eighty thousand 
persons died in Ireland, of fever, dysentery, and famine. Dr. 
Rutty, then a practising physician in Dublin, informs us that, "in 
the autumn of 1740, there was a great dearth of provisions in 
Ireland, which proceeded almost to a famine in winter, the pota- 
toes having failed, whilst other provisions bore double or treble 
their usual price." A subsequent epidemic of 1800 and 1801 
was also attended by a great scarcity of provisions. Again, the 
terrible epidemic of 1817, 1818, and 1819, was preceded, and 
during a portion of the time at least, and in many places accom- 
panied, by a dreadful deficiency of even the commonest food. 
There are few darker pages in the long, sad annals of Irish poverty 
and disease, than that upon which is written the history of this 
epidemic. 2 The crops of 1816 had almost entirely failed, and 

1 Pringle's Dis. of the Army, p. 255. 

2 Let me add, in a note, that many of these otherwise gloomy pages are made 
radiant and luminous with affecting examples of the patient resignation of the 
poor sufferers ; and of the self-forgetfulness and devotion of the Roman Catholic 
clergy, the physicians, and other benevolent friends of the sick. Few incidents 



CAUSES. — CROWDING, FILTH, FAMINE, ETC. 251 

the same thing was true to a considerable extent of the following 
year. Not only was a large portion of the grain destroyed by 
the unfavorable weather, but the little that was saved was of a 
poor quality. 

It would be wrong, however, to attribute this or any of the 
preceding epidemics to famine alone. Typhus fever is constantly 
present in various parts of Ireland, and it has more than once 
extensively prevailed when the harvests had been good, and food 
unusually abundant. This is only one of many co-operating in- 
fluences, to which the wide-spread prevalence of the disease is to 
be attributed. 

Many of the Irish writers often speak of having seen typhus 
fever occurring several times in the same individual. Dr. Stoker 
speaks of the poor as having frequent attacks of fever, in the 
course even of a short life, and thinks that few adults have escaped 
these attacks, although he has no doubt that the succeeding at- 
tacks are milder than the first. Dr. O'Brien, in one of his hos- 
pital reports, says : " Some of the nurses have had the disease 
three or four times." Others have remarked that a second attack 
of the disease is very rarely witnessed when the first had been 
severe, or when it had been attended by an abundant eruption. 
And there seems good reason for believing that such is the case. 
Dr. Barker, in his Report of the Cork Street Hospital, Dublin, 
states that he has for some time entertained the opinion that suf- 
ferers from fever, attended with the petechial eruption, if they 
are not altogether secured by it from a second attack, are not at 
least so liable to it as those who have had a fever of the ordinary 
kind. "Though I have frequently made the inquiry," he adds, 
"I have not found a patient in whom this symptom was distinct, 
who had suffered from the same fever on any former occasion. 
But, whatever may be the result of more minute inquiry, it may 
be asserted that the chances of the recurrence of fever diminish 
in proportion to the continuance and severity of the first attack." 
Dr. Bracken, of Waterford, after quoting the above, says: "It 
appears to me that this opinion is supported by experience, as 
well as by reasoning from similar facts. Since I first observed 

in medical biography are more touching and beautiful than the sketch -which is 
given of the early death of young Gillichan, of Dundalk, one of the many mar- 
tyrs to science and humanity, whose brief lives shed light and glory on the history 
of our art. 



252 TYPHUS FEVER. 

this remark, I have kept the subject in view, and, after some 
attention to it, I have not been able to ascertain that more than 
three persons, out of many hundreds who came within my obser- 
vation, have had relapse or recurrence of fever, after being pre- 
viously affected with the symptoms in question." 1 Dr. Trotter 
says: " During our extensive and long experience of the origin, 
progress, and extinction of contagion, in ships, and everywhere 
else, I have entertained a strong suspicion that typhus infection 
very seldom affects a person more than once in a lifetime." 2 Dr. 
Perry, of Glasgow, in a letter to the editors of the Dublin Jour- 
nal of Medical Science, says : "I have for some years entertained 
the opinion, founded upon an extensive series of observations, 
that contagious typhus is an exanthematous disease, and is 
subject to all the laws of the other exanthemata ; that, as a 
general rule, it is only taken once in a lifetime, and that a 
second attack of typhus does not occur mOre frequently than a 
second attack of smallpox; and, judging from my own expe- 
rience, less frequently than a second attack of measles or scarlet 
fever." 

Sec. VI. — Age. There is no evidence that this disease is con- 
fined to any period or periods of life. During its prevalence at 
Philadelphia, in 1836, children were rarely attacked by it ; but 
after childhood, age seemed to exercise little or no influence upon 
the susceptibility to the disease. Amongst the whites, ^where the 
age could be better ascertained than amongst the blacks, there 
were as many patients over thirty-five years old as there were 
under this age. Dr. Edward Percival, in his Report on the 
Epidemic Fevers of Dublin, at the Hardwicke Fever Hospital, 
during the years 1813, 1814, and 1815, says that the disease 
prevailed continually amongst the boys and girls of the Bedford 
Asylum ; characterized by petechiae, great failure of strength, a 
turgid countenance, and considerable stupefaction. 3 Eleven hun- 
dred of these children were crowded together in a building ori- 
ginally intended to accommodate only six hundred. Of three 
thousand nine hundred and seventy patients, received into the 
Cork Street Hospital, Dublin, in 1817 and 1818, there were under 

1 Barker and Cheyne's Account, etc., vol. i. p. 241. 

2 Medecina Nautica, p. 213. 3 Trans, of Phys. of Ireland, vol. i. p. 288. 



CAUSES. — AGE. 253 

ten years of age three hundred and sixt y-two ; from ten to twenty 
years, fourteen hundred and seventy-four ; from twenty to thirty 
years, twelve hundred and sixty-five ; from thirty to forty years, 
five hundred and eight ; from forty to fifty years, two hundred and 
forty-one; and over fifty years, one hundred and twenty. 1 Dr. 
Barker says that, in the course of the epidemic of the above-men- 
tioned years, he witnessed the disease in many children under 
the age of four or five years, and in its most exquisite form — that 
of petechial fever. It will be found from extensive observations, 
that a large proportion of the cases of typhus fever occur in per- 
sons who are between the ages of fifteen and thirty years ; but it 
would be very unsafe to infer from this fact anything positive as 
to the liability of different ages to the disease, unless we have 
first ascertained the whole number of persons of these different 
ages exposed to the causes of the fever. From not attending to 
this and other circumstances in these calculations — from not taking 
into account all the elements of the problem to be solved — many 
writers have lost themselves on what Dr. Arrott, of Dundee, calls 
the " quicksands of false arithmetic." 

The average age of forty-seven patients, in whom the disease 
proved fatal at the Royal Infirmary of Edinburgh, in 1838 and 
1839, was thirty-five years and a half, nearly. 2 

Sec. VII. — Sex. The influence of sex in predisposing to 
typhus fever is not very great. It has been generally remarked 
by Irish observers, that the disease is somewhat more common 
amongst females than it is amongst males. This fact may be in 
part, perhaps entirely, accounted for, by the more constant expo- 
sure of the females to many of the most active causes of the dis- 
ease. From Dr. Mateer's statistics, it appears that, of 9588 
patients admitted into the Belfast Fever Hospital between May, 
1813, and May, 1835, inclusive, 5130 were females and 4458 
were males. Dr. Harty gives a table of the admissions and 
deaths of the two sexes, at some of the principal hospitals of Ire- 
land, from 1817 to 1819. Jhe number of males admitted was 
32,144; the number of females 34,398. The male mortality was 
one in 19.40 ; the female, one in 24.75. 3 In connection with this 

1 Trans, of Phys. of Ireland, vol. ii. p. 533. 

2 Ed. Med. and Surg. Journ., Oct. 1839. 3 Historic Sketch, etc., p. 29. 



254 TYPHUS FEVEK. 

subject, Dr. Harty remarks that : " Though it is well ascertained 
that the epidemic spared neither age, sex, nor condition, and that 
all were indiscriminately exposed to its attacks, it is yet certain 
that there were particular periods of the epidemic season, during 
some of which children, during others adult females, and during 
others adult males, predominated in number." 1 

Sec. VIII. — Recency of Residence. New residents in any 
given locality seem to be somewhat more liable to typhus than 
others, although this circumstance has so little influence that it 
has not been often spoken of by British writers. According to a 
table published by Dr. Davidson, of five hundred and sixty-eight 
patients with typhus, admitted into the Glasgow Fever Hospital, 
in 1838 and 1839, one hundred and seventy-six, or one-third, 
nearly, were natives of the city ; one hundred and ten had been 
residents less than six months ; fifty-five, from six months to a 
year ; ninety-seven from one year to five ; and one hundred and 
thirty, from five years to twenty and upwards. Thus more than 
half of the whole number had lived in the city five years or up- 
wards. 2 

1 Historic Sketch, etc. p. 31. 2 Dunglison's Medical Library. 



255 



CHAPTER V. 

VARIETIES AND FORMS. 

The most common varieties of typhus fever are such as de- 
pend upon different degrees of severity, and such as are more or 
less constantly connected with the different seasons of the year. 
The proportion of mild to grave cases varies considerably under 
different circumstances, but it is almost always very great. Cases 
of all degrees of intensity, from the mildest to the most severe 
and malignant, just as happens so frequently with scarlatina, and 
smallpox, are often found together, under the same circumstances, 
and apparently depending upon similar causes. 

During the winter and spring, the disease is more likely to be 
seriously complicated with pulmonic affections. In the summer 
and autumn, it is frequently associated with gastro-intestinal irri- 
tation. The disease in certain places, and for a limited period 
of time, is occasionally marked by certain peculiarities. Dr. John 
Cheyne remarks that he never witnessed continued fever with so 
many inflammatory symptoms, as in the spring and summer of 
1816, at Dublin ; and that the blood was sizy in nearly one-half 
of the patients who were blooded. In August and September, 
the cases were often complicated with dysentery, and with symp- 
toms of gastro-hepatic derangement. A distressing nausea was 
common, with a bitter or foul taste, and a yellow tongue. After 
this period, the fever became more severe in its character, and 
was frequently complicated with an inflammatory state of the 
bowels. 1 In December, and the following January, many cases 
were attended with inflammation of the bronchial mucous mem- 
brane. The same writer says that, of one hundred and seventy- 
five patients, admitted into two wards of the Hardwicke Hospital 
during the months of April, May, and June, 1818, at least three- 
fourths had cough, with pains or stitch, oppression in the chest, 

1 Dub. Hosp. Rep., vol. i. p. 15, et seq. 



256 TYPHUS FEVER. 

and quickened respiration." 1 But these varieties are in no degree 
more numerous or more important than those which are observed 
in the history of all epidemic diseases. Certain individual symp- 
toms or phenomena may be frequent at one time and place, and 
rare at another. The occurrence of epistaxis, for instance,, or of 
relapses, or of some consecutive affection, may be much more 
common in one season than in another. Dr. John Cheyne says 
of the fever at Dublin in 1816 : "Relapses, which rarely occurred 
in summer, were uncommonly frequent in winter." 

During the years 1843 and 1844, there prevailed very exten- 
sively, at Edinburgh, a form of fever marked by such strong 
peculiarities as to excite some question as to its true character. 
Dr. Alison believed it to be specifically distinct from typhus. 
A very elaborate history of the disease has been published by 
Dr. Halliday Douglas, in the Northern Journal of Medicine. 
It was generally sudden in its attack, and rapid in its progress. 
One of its most striking peculiarities consisted in its tendency to 
terminate suddenly, after a certain period, by a critical evacua- 
tion — commonly by sweating — and after an apyrectic interval to 
relapse. This sometimes happened twice. Of one hundred and 
twenty-one cases admitted into the Edinburgh Royal Infirmary 
during the primary attack, the period of the first crisis was as- 
certained in eighty-three. It occurred on the fourth day, in two ; 
on the fifth day, in twelve ; on the sixth day, in twenty-five ; on 
the seventh day, in twenty-seven ; on the eighth day, in nine ; on 
the ninth day, in four ; and on the tenth day, in four. Only six 
of the remaining thirty-eight are said to have recovered gradu- 
ally, and not by an abrupt crisis. The crisis was in most in- 
stances preceded by a rigor or chilliness; and in all but two 
cases, accompanied by a sweat more or less profuse, lasting gene- 
rally for a few hours, in a few cases for two or three days. Some- 
times, during the sweat, the pulse increased in frequency, but not 
always. The apyrexial period or intermission was quite complete 
in all but fifteen cases. Its usual duration was from five to seven 
days. The relapse was almost universal. Of one hundred and 
forty cases in which the time of its occurrence was ascertained, 
it took place between the ninth and thirteenth day of the fever, 
in seventeen ; on the thirteenth, fourteenth, and fifteenth days, 

1 Dub. Hosp. Rep., vol. i. p. 15, et seq. 



VARIETIES AND FORMS. 257 

in eighty-one ; and subsequent to the fifteenth day, in forty-two. 
The relapse was generally ushered in by a rigor, and followed by 
febrile symptoms, less urgent, however, and of shorter duration 
than in the primary attack. This relapse usually terminated by 
a second crisis, between the second and the fifth day, inclusive, 
from its commencement. In eleven cases, there was a second 
relapse, occurring at different periods, from the eighteenth to the 
thirty-sixth day of the disease. The duration of the second re- 
lapse varied from one to five days. The access was generally 
accompanied by epigastric distress and bilious vomiting. In a 
certain proportion of cases the patients became jaundiced. Dr. 
Douglas says the frequency of this occurrence has been exag- 
gerated. He met with it in only twenty-nine of two hundred 
and twenty cases. The epidemic was marked by some other 
minor peculiarities. 

The disease referred to in the above paragraph, has attracted 
a good deal of attention in Great Britain, during the last few 
years. Dr. Jenner has described it carefully and minutely under 
the name of Relapsing Fever. He regards it as a specific dis- 
ease, differing, clearly and distinctly, from both typhus and ty- 
phoid fever. The following is Dr. Jenner's definition of the dis- 
ease. " Sudden rigors, headache, skin hot and dry, tongue 
white, urine high-colored, bowels regular, occasional or frequent 
vomiting, loss of appetite, absence of abnormal physical ab- 
dominal signs. In severe cases, jaundice, profuse sweating on 
about the seventh day, followed by apparent restoration to health ; 
on from the fifth to the eighth day, reckoning from the apparent 
convalescence, repetition of the original symptoms, with greater 
or less severity; again terminating in sweating, and then perma- 
nent convalescence." 1 

I have said nothing about the old Cullenian division of con- 
tinued fever into synocha, synochus, and typhus, for the suffi- 
cient reasons that this division is altogether arbitrary and conven- 
tional ; and that, although some few of its illustrious author's 
countrymen still cling to it, it is very generally and very proper- 
ly abandoned. 

1 Jenner on the Identity or Non-Identity of the specific causes of Typhoid, 
Typhus, and Relapsing Fever, p. 4. 

17 



258 



CHAPTER VI. 

DUKATION AND MARCH. 

Sec. I. — Duration. The duration of typhus fever varies very 
considerably in different easel, and under different circumstances. 
Death often takes place at an earlier period than ever happens 
in typhoid fever. Dr. O'Brien says that death is not unfrequent 
on the fifth or sixth day of the disease. Dr. Pickels " remarks 
that the disease, when fatal, rarely exceeded the eleventh or 
thirteenth day, and in many cases that it was much shorter. Dr. 
Edward Percival noticed that death was most common between 
the eleventh and seventeenth days. Dr. Bracken, of Munster, 
in a communication to Drs. Barker and Cheyne, says that, in the 
epidemic of 1817, 1818, and 1819, the greatest number of deaths 
took place on the ninth day ; and then successively, on the tenth, 
twelfth, eleventh, seventh, and eighth. 

The statements of most of the Irish writers, in regard to the 
average duration of the disease, are not, I think, to be very con- 
fidently relied upon. They do not tell us in what manner the 
duration was estimated, nor what mode was adopted for fixing 
the commencement and the termination of the cases. Dr. Lyne 
of Fralee, says that, in the epidemic of 1817, 1818, and 1819, 
the duration of the disease ranged from five to twenty days, the 
average period being fourteen days. 1 Dr. Bracken, of Munster, 
estimates the average duration in the same epidemic at nine days 
before puberty, and at fourteen days for adults. 2 Dr. Pickels, 
in his Report of the South Fever Asylum, at Cork, for 1817, 
1818, and 1819, says that, of fifty-nine cases taken in succession 
under the age of sixteen years, and which recovered, thirty-seven 
did not exceed the tenth day, and twenty-two did ; and that of 
sixty cases, over the age of sixteen, which recovered, nine did 
not exceed the tenth day, and fifty-one did. 3 The testimony of 

1 Barker and Cheyne's Account, etc., vol. i. p. 154. 2 Ibid., vol. i. p. 304. 
3 Trans, of Phys. of Ireland, vol. iii. p. 203. 



DURATION AND MARCH. — CRISES. 259 

the Irish observers is very unanimous as to the shorter duration 
of the disease amongst the young than amongst adults. It is less, 
also, in mild than it is in grave cases. Dr. Stoker found at the 
Cork Street Hospital, Dublin, in the summer of 1818, that of 
four hundred and seventy-one cases, mostly mild, nearly three- 
fourths terminated on or before the seventh day. 

Dr. Alexander P. Stewart says that the mean duration of 
typhus fever at Glasgow, calculated from the results of many 
thousand cases during successive years, is about twenty-one days. 1 
Dr. Henderson says that the average date of commencing con- 
valescence at the Royal Infirmary of Edinburgh, in 1838 and 
1839, was the thirteenth day. The average period at which 
death took place, calculated by Dr. Reid from one hundred and 
forty-three cases, was between the twelfth and the thirteenth 
day. 2 

Sec. II. — Crises. Many of the Irish writers on typhus fever 
allege that, in very frequent instances, the disease terminates in 
what has been called a crisis. That the commencement of con- 
valescence, in this as well as in many other diseases, should be 
formally and pretty clearly marked by certain phenomena of a 
decided character, is what we can easily understand, and what 
we frequently sec. The coming on, after its long absence, of 
quiet and protracted sleep, accompanied as this grateful and re- 
freshing visitation often is, with a diminution in the frequency of 
the pulse, a restoration of the integrity of the mind, and a change 
in the state of the skin, from an arid heat to a warm, gentle, and 
equable moisture, most certainly indicates a great and radical 
revolution in the condition of the system, which may well be called 
a crisis. But something more than this formal and obvious change 
in the state of the living tissues from a morbid to a healthy 
action is often meant, I think, by writers who speak of these 
crises in typhus and other fevers. They tell us of a violent 
struggle in the suffering economy, which precedes and accompa- 
nies the transition of the functions from their diseased and per- 
turbed action to their natural and easy play. They speak as 
though the recuperative powers of the system, almost worn out 

1 Edin. Med. and Surg. Journ., Oct. 1840. 
a Ibid., Oct. 1839, and Aug.' 1842. 



260 TYPHUS FEVER. 

or overcome by the morbific influences which have obtained pos- 
session of the organs, had now gathered up and concentrated all 
their remaining energies ; had now taken their desperate and 
final stand against the further inroads and ravages of disease ; 
and as though the perturbation resulting from this conflict con- 
stituted the critical struggle, terminating, as the case may be, 
either in recovery or in death. This is neither an unfair nor an 
exaggerated statement of the views of these observers. Thus 
Dr. Percival, in his Hardwicke Fever Hospital Report, for 1813, 
1814, and 1815, says : " The critical period was often a scene of 
severe struggle, the issue of which was for many hours doubtful. 
An obscure rigor would set in on the eve of the fourteenth day, 
or later ; delirium and jactitation would increase, the extremities 
become cold, respiration hurried and oppressed; the countenance 
pale and anxious ; and the pulse, by its frequency, smallness, and 
irregularity, scarcely numerable. The patient would often moan 
loudly, from pains referred by him to the bones of his back and 
limbs. This struggle usually increased for some hours, and then 
subsided into relief or the gradual extinction of life." 1 Dr. 
Percival, also, expresses the opinion that the term of convales- 
cence was lengthened or shortened, in proportion as the crisis 
was fully or obscurely formed. Dr. Cheyne, in his Hospital 
Reports, makes very frequent mention of crises, marked by rigors 
succeeded by sweats. He noticed this termination of the fever 
much oftener during some periods than in others. Thus he says 
that, between the 12th and the last of May, 1817, amongst fifty-nine 
patients admitted into the Hardwicke Hospital, there were twenty 
instances of this form of critical resolution, although, previous to 
this time, he had good reason to think that such a termination 
was exceedingly rare. " The rigor of crisis," as Dr. Cheyne 
calls it, he says rarely lasts long ; perhaps only a few minutes, 
perhaps half an hour or an hour. Another form of crisis is thus 
characterized by the same accurate observer: "A state of rest- 
lessness and anxiety, with flushing of the face, rapid pulse, fre- 
quent, laborious breathing, and increased heat of the surface, 
with great distress at the pit of the stomach from heat, tender- 
ness, or pain; which distress was not unfrequently relieved by 
vomiting. The patients were in a state of universal uneasiness, 

1 Trans, of Phys. of Ireland, vol. i. p. 299. 



DURATION AND MARCH. — CRISES. 261 

which would have been truly alarming had we not known its 
tendency ; but this state is well understood, even by the servants 
of a Fever Hospital, who soon come to know by these symptoms 
that the patient is near ' the cool.' This state sometimes lasted 
for the greater part of a day, during which time one of our ex- 
perienced nurses, who was fond of figurative language, would 
generally remark that Hhe cool was hovering rounoV the patient." 1 
Whatever was the form of this " salutary effort" it was generally 
completed by a warm perspiration flowing from the whole sur- 
face of the body. Dr. Cheyne enumerates many other occasional 
modes of crisis, which seem to have consisted merely in the 
occurrence of some more or less striking symptom, such as diar- 
rhoea or expectoration, or a simple chill, just preceding or at the 
commencement of convalescence; and concludes the subject by 
saying that, in many instances, he could not discover any critical 
effort, the disease gradually terminating, as some of the older 
authors have remarked, by " insensible resolution." 

Dr. Stewart, of Glasgow, in reference to this subject, says : 
" All that I insist upon is the frequent, I may say the common, 
occurrence of a perceptible crisis, or what is vulgarly termed a 
turn in typhus. I think I may appeal to the experience of every 
physician, and more especially of every resident clerk in a fever 
hospital — for they have more constant opportunities of observa- 
tion — whether they have not often been struck at seeing, during 
their morning visit, the glassy eye, the haggard features, the low, 
muttering delirium, the stupor approaching to coma, the tremor, 
the subsultus, the carphology, the rapid, thready, tremulous, and 
intermittent pulse, of the previous evening ; the formidable array 
of symptoms, in short, which seemed to indicate a speedy and 
fatal termination, exchanged for the clear eye, the intelligent 
countenance, the steady hand, the comparatively slow and firm 
pulse, and the returning appetite of approaching convalescence. 
To such cases as these, we might almost apply the Scripture 
phrase, ' At such an hour, the fever left him ;' and if the crisis is 
not very frequently so marked, we can, in the great majority of 
cases, point with precision at least to the day on which amend- 
ment began to take place." 2 

1 Dub. Hosp. Rep., vol. ii. p. 17. 

2 Edinburgh Med. and Surg. Journal, Oct. 1840. 



262 TYPHUS FEVER. 

The following is Hildenbrand's description of the stage of the 
disease, immediately succeeding to the crisis. It constitutes his 
seventh period. " The first striking symptom that disappears is 
the delirium. The patient awakes, as it were, from a dream, or 
a fit of intoxication ; his head becomes free, and in some in- 
stances he has an instantaneous and perfect recovery of his for- 
mer knowledge. The memory, however, is still peculiarly affected; 
so much so that the patient has great difficulty in recalling to 
mind the circumstances that passed before and during his illness. 
The mind also experiences a considerable change, and the indif- 
ference which was previously observed in the patient now begins 
to disappear. The eye becomes more attentive and expressive ; 
surrounding objects begin to excite an interest, and the patient 
takes more notice of what is going on ; the insensibility of the 
soul is dissipated ; and the feelings of gratitude, of love, and of 
friendship, as well as of every other sentiment of the soul, are 
gradually awakened and displayed in the most exalted degree. 

" While the nervous system resumes its ordinary functions, and 
the locomotive powers become more energetic, the functions of 
the circulation are re-established, and the pulse becomes calm, 
regular, and open, though it is frequently weaker than in the 
preceding stages of the disease ; the heat and perspiration of the 
body become mild and uniform ; the thirst completely disappears, 
and the drinks which formerly afforded so much comfort to the 
patient now become disgusting." 1 Hildenbrand also notices par- 
ticularly the extreme muscular debility which accompanies this 
stage of the disease. 

Sec. III. — Sequelae. Typhus fever is not often followed by 
chronic affections which can be referred to the previous disease. 
Dr. Cheyne and some others speak of an occasional case of 
phthisis, chronic rheumatism, hydrothorax, and so on, as 
amongst the sequelae of typhus fever ; but the general testimony 
of the Irish physicians is against the frequency of such results. 
This is very striking in the Reports from many districts of the 
country, which are published in Barker and Cheyne's account 
of the epidemic of 1817, 1818, and 1819. They almost all 
agree in saying that the disease rarely left any dreg behind it. 

1 Gross's Hildenbrand, p. 52. 



DURATION AND MARCH. — RELAPSES. 263 

Sir Gilbert Blane noticed that ships arriving in the West Indies, 
from England, with their men suffering from typhus, were more 
liable than others to extensive visitations of dysentery. 1 



Sec. IV. — Relapses. The statements of British writers in re- 
gard to the frequency of relapses are quite contradictory. In 
most of the communications contained in Barker and Cheyne's 
history of the epidemic of 1817, 1818, and 1819, relapses are 
stated to have been of very frequent occurrence. At Cork, the 
number of persons who relapsed was estimated at two thousand. 
At Waterford, the relapses amounted to one-fifth or one-sixth of 
the whole number of the sick. 2 This tendency to relapse was 
most striking during the latter period of the epidemic. It would 
seem to exist during certain periods, and to be absent during 
others. Dr. Stewart says that, however long may be the period 
of excitement, however long the adynamic stage, however tedious 
the period of convalescence, he has never, amongst thousands of 
cases, seen a single case of relapse, in the proper sense of the 
term, after the symptoms had begun to decline. 3 Dr. Edward 
Percival says that relapses were extremly rare at the Hardwicke 
Fever Hospital; while Dr. Pickels speaks of them as common, 
though mild, at Cork. Dr. Alfred Hudson, in his elaborate In- 
quiry into the sources and mode of action of the Poison of Fever, 
informs us that, in five hundred cases of fever admitted into the 
Navan Hospital in 1840, only two instances of true relapse oc- 
curred. 4 These differences of statement may depend, in part at 
least, upon relapsing fever having been confounded with typhus. 

1 Obs. Dis. of Seamen, p. 356. 

2 Barker and Cheyne's Account, etc., vol. i. p. 439. 
a Edinburgh Med. and Surg. Journ., Oct. 1840. 

4 Dunglison's Medical Library. 



264 



CHAPTER VII. 

MORTALITY AND PROGNOSIS. 

The average mortality of typhus fever, deduced from large or 
considerable numbers, like that of most other epidemics of a 
grave Character, differs very greatly in different seasons and 
localities. Before proceeding to estimate the elements "of our 
prognosis in individual cases, I will endeavor to ascertain, as 
nearly as our materials will allow this to be done, the general 
rate of mortality in this disease, and some of its variations under 
different circumstances. 

It is estimated by Drs. Barker and Cheyne, in their admirable 
history of the great Irish epidemic of 1817, 1818, and 1819, that 
the number who suffered from typhus fever in that country, be- 
tween the commencement of the first-mentioned year and the 
middle of the last, embracing a period of only two and a half 
years, amounted to fifteen hundred thousand; and that the aggre- 
gate number of deaths was sixty-five thousand, making the ave- 
rage mortality one in twenty -three. The number of patients 
received into the Cork Street Fever Hospital, of Dublin, between 
the 14th of May, 1804, and the 5th of January, 1816, embracing 
no remarkable epidemic period, was twenty thousand two hun- 
dred and seventy-eight. The highest mortality was one in ten, 
in the year 1805 ; the lowest was one in nearly twenty, in the 
year 1815 ; and the average mortality, for the entire period, was 
about one in fourteen. Dr. O'Brien, in the Report from which 
these results are obtained says, that the hospital necessarily re- 
ceived an undue proportion of grave and dangerous cases ; so that 
the rate of mortality amongst fever patients was somewhat higher 
in the hospital than in the city at large. 1 The whole number of 
patients received into the several fever hospitals of Dublin, from 
the 31st of August, 1817, to the 1st of October, 1819, was forty- 

1 Trans, of Phys. of Ireland, vol. i. pp. 446, 461. 



MORTALITY AND PROGNOSIS. 265 

one thousand seven hundred and seventy-five; and the deaths, 
during this period, were one thousand nine hundred and seventy- 
one ; making the rate of mortality one in twenty-two, nearly. 1 
The highest rate, for any single quarter, was one in fifteen ; the 
lowest, for any single quarter, was one in thirty-two. The ave- 
rage mortality, during the same epidemic, in the South Fever 
Asylum at Cork, was one in twenty-five. 

The influence of age, sex, season, and the condition and con- 
stitution of the patient, upon the danger of the disease, and upon 
our consequent prognosis, constitutes an interesting and important 
subject of inquiry. 

Typhus, like typhoid fever, is less severe and fatal in early 
than in middle life. Dr. Percival says that, amongst the children 
who were timely removed from the crowded apartments of the 
Bedford Asylum, to the cool and ventilated wards of the hospital, 
and who were properly treated, the fever seldom continued longer 
than seven days in any case, and hardly ever proved fatal. 2 Dr. 
Baker observes that very few children became the victims of the 
epidemic in the years 1817 and 1818. Amongst the numerous 
cases of children which came under his care, he recollects but 
one which terminated fatally; and in that instance, death was 
occasioned by the supervention of another disease. 3 Dr. John 
Cheyne says of the fever of 1818, at the Hardwicke Hospital, 
that persons under twenty-five years of age had the disease mildly. 
This influence of age upon the mortality of typhus fever is placed 
in a very clear and striking light by the statistical researches of 
Dr. Mateer. I copy the following table from a paper of his, in 
the tenth volume of the Dublin Journal of Medical Science, ex- 
hibiting the effects of age upon the mortality of the disease, at 
the Belfast Fever Hospital, from September, 1817, to May, 1835. 



Admitted, 5214; died, 
151 ; being a mortal- 
ity of nearly 3 per 
cent., or 1 in 34 84- 
151. 

Admitted, 3747; died, 
301; being a mortal- 
ity of 8 per cent, and 
a fraction, or 1 in 12 
135-301. 

1 Trans, of Phys. of Ireland, vol. iii. p. 456. 2 Ibid., vol ii. p. 572. 

3 Ibid., vol. i. p. 288. 





Age. 


No. of Cases. 


Deaths. 




Mortality 


rom 


1 to 5 


years 


301 


12 


1 


in 25 f 3 


<( 


5 to 10 


<< 


979 


13 


1 


in 75 T 4 S 


" 


10 to 15 


<< 


1709 


36 


1 


in 47±| 


«< 


15 to 20 


ii 


2225 


90 


1 


in 24f* 


rom 


20 to 25 


ii 


1384 


74 


1 


in 24*| 


«« 


25 to 30 


" 


1033 


81 


1 


in 12f} 


n 


30 to 35 


ii 


677 


70 


1 


in m 


a 


35 to 40 


ii 


553 


76 


1 


^ m 



TYPHUS FEVER. 

Age. No. of Cases. Deaths. Mortality. 

From 40 to 45 years 418 82 1 in 5/^ Admitted, 1043; died, 

" 45 to 50 " 302 60 1 in 5 A 216; being a mortal- 

« 50 to 55 - 188 45 1 in 4 A \ ^ ^t fl?9- 

« 55 to 60 " 135 29 1 in 4£f J 216. 

From 60 to 65 « 86 31 1 in 2fH Admitted, 171; died, 

" 65 to 70 " 36 12 1 in 3 I 60 ; being a mortality 

" 70 to 75 " 25 11 1 in 2 A | °f35 15-171 per cent., 

« 75 to 80 » 24 6 1 in 4 J ° r X in 3 nearly ' 

Results very similar to the above are shown by an examination 
of the cases received into the Royal Infirmary of Dundee, in 
1836 and 1837. 

It has been very generally observed, amongst the hospital pa- 
tients in Ireland and Scotland, that the rate of mortality is much 
influenced by the period of the disease at which the patient is 
received ; it being much less in those cases that are received in 
the early than in those that are received in the late stages of the 
fever. This may depend in part upon the circumstance that the 
severity of these cases, sent late to the hospital, would be likely 
to be greater than that of the general average. This influence 
is very well shown by the following calculation, made by Dr. 
Mateer, and founded upon a grand total of 9588 patients, treated 
in the Belfast Fever Hospital, during a series of seventeen conse- 
cutive years. 

Admitted 1 } 2d Sd 4th 5th 6th 7th 8th 9th 10th llth 12th 13th 14th TotaL 
No of 



2 3 4 4 4 6 11 10 10 6 10 4 20 



No. deaths. 13 41 82 52 39 40 112 30 57 13 25 7 150 

Ratio of 

mortality 

per cent. ; 

fractional 

Nos.omit- 

ted. 

It has been observed as a general rule, in Ireland, that the 
mortality is considerably greater amongst men than it is amongst 
women. During certain periods, and in given localities, this 
difference is very obvious. Thus, at the Cork Street Fever Hos- 
pital, Dublin, in 1817 and 1818, the rate of mortality amongst 
the males was one in sixteen ; while amongst the females it was 
only one in twenty. 1 During the same epidemic, however, at 
Cork, the mortality in the South Fever Asylum was, amongst 

i Trans, of Phys. of Ireland, vol. ii. p. 568. 



PROGNOSIS. — CONDITION. 267 

males, one in twenty-eight and a half, and amongst females one 
in twenty-three. 1 During a period of eighteen consecutive years, 
from 1818 to 1835, at the Belfast Fever Hospital, the ratio of 
deaths was, for females, one in fourteen, nearly ; and for males, 
one in seventeen. 2 The rate of mortality in the Royal Infirmary 
of Dundee, omitting fractions, in 1836 and 1837, was for females, 
one in eighteen ; and for males, one in eleven. It ought how- 
ever to be remembered, in partial explanation of this difference, 
that, in many places, the average age of the female is less than 
that of the male patients. Barker and Cheyne say : " We be- 
lieve that at all times fever, particularly when it assumes a severe 
form, is more fatal to men than to women." 3 

Although the poor are very much more subject to typhus fever 
than the rich, and those who are well provided with the material 
comforts and luxuries of life, it is a singular fact that the dis- 
ease, when it does occur in the latter class, is more severe and 
dangerous than when it occurs in the former. The testimony of 
the Irish physicians to the truth of this circumstance is almost 
unanimous. Old Rutty, in speaking of the great epidemic of 
1740 and 1741, says : " The poor, abandoned to the use of whey, 
and God's good providence, recovered; ivhile those who had gene- 
rous cordials, and great plenty of sack, perished.' ' Barker and 
Cheyne say : " In every part of the country, fever was reported 
to have been much more fatal amongst the upper than the lower 
classes." 4 Of eleven physicians at Cork, who had the disease in 
1819, four became its victims. At Waterford, at Fermoy, and 
at Cork, the mortality amongst the upper classes ranged from 
one-third to one-fourth of the whole number attacked. 5 The 
mortality amongst the young physicians attached to the New 
York hospitals has been very great. 

Mental anxiety and distress seem to predispose to a grave 
form of the disease. The Irish writers have generally observed 
that fathers of families, and others, whose character and circum- 
stances in life were such as to occasion great depression of spirits, 
and apprehension for the future, were more subject to severe and 
dangerous attacks than those of a different temperament, and in 
different situations. Dr. Bracken, of Waterford, says : " In the 

1 Trans, of Pkys. of Ireland, vol. iii. p. 230. 

2 Dublin Journ. of Med. Science, vol. x. p. 40. 

3 Account, etc., vol. i. p. 90. 4 Ibid., vol. i. p. 95. 6 Dbid., p. 435. 



268 TYPHUS FEVER. 

winter and spring of 1806-7, the attention of the writer was 
forcibly directed to the fatal effect of fever on the fathers of 
families. Several families with fever were admitted during that 
period into the Royal Infirmary of Edinburgh, of which the 
heads, almost without exception, became victims, while the 
rest escaped. Similar coincidences have since that time been 
repeatedly observed by him. Scarcely any medical person needs 
to be informed that the age, habits, probably bad, or diseases 
derived from them, together with the greater mental anxiety 
and solicitude, naturally belonging to persons in this relative 
situation in life, must materially enter into the prognosis in all 
cases, and frequently have the worst effects on the termination 
of the disease." 1 Dr. Edward Percival remarks that "fevers 
which had been preceded by great bodily fatigue and mental 
anxiety were uniformly hazardous." Dr. Pickels says: " The 
disease was very fatal amongst the old, and those who were de- 
bilitated by previous diseases, especially asthma. Of six or 
seven blacks who had the fever in Cork, all died but one." Dr. 
Arrott, of Dundee, thinks that, of all circumstances increasing 
the danger and mortality of typhus, the previous habitual use of 
intoxicating drinks is the most powerful. 

Barker and Cheyne say : " It is a general remark that epi- 
demic diseases are most fatal on their invasion ; and in conformity 
with experience we find that the late epidemic fever — that of 
1817, 1818, and 1819, was most mortal at its commencement. 
This is proved by reference to various documents. Thus it ap- 
pears, from a tabular view of the admissions to the Fever Hospi- 
tal in Cork Street, that the mortality decreased from 62 in 1000, 
to 31 in 1000. " 2 A similar difference was observed in the epi- 
demic of 1800 and 1801. 

Our prognosis in individual cases must depend upon a careful 
appreciation of all the foregoing circumstances, and especially 
upon the degree of severity of a certain number of the symptoms. 
Great prostration of strength at an early period of the disease, 
profound coma, and dark purple or livid petechia, are amongst 
the most unfavorable symptoms. Dr. Gerhard says that, in the 
Philadelphia epidemic, when the stupor was extreme, so as almost 
to amount to coma, the prognosis was nearly always fatal. Dr. 

1 Barker and Cheyne's Account, etc., vol. i. p. 198. 2 Ibid., vol. i. p. 88. 






PROGNOSIS. — ERUPTION. 269 

Edward Percival says : " The worst symptoms of fever are per- 
vigilium, tympany, singultus, and coma; the most favorable in 
all cases are sleep, a moist tongue, and solvent bowels ; a defi- 
ciency of urine is also an unfavorable sign, and its suppre- 
very commonly a fatal one. When the patient lies at ease on 
his side, and especially if he is observed to relieve himself by 
spontaneous changes of position, after the fever is much advanced, 
the augury is favorable; on the contrary, when he continues ex- 
tended and supine, lethargic and muttering, the prognostic is 
adverse." 1 Dr. Bateman speaks thus of the tongue : "The most 
important indications afforded by the appearance of the tongue 
are perhaps to be deduced from its changes ; that is, from its 
tendency to return to the natural state, whatever the character 
which it usually maintains throughout may be. If the clammy 
tongue becomes cleaner, the parched one begins to lose its shin- 
ing appearance, and to exhibit its papillae surrounded with 
moisture, or the crust of the coated one to soften and loosen, we 
may generally anticipate a favorable change in the other symp- 
toms, if it have not at the same time occurred. Perhaps we may 
with equal confidence prognosticate favorably of the issue of a 
fever, in which the tongue retains much of its natural appearance 
in the midst of many untoward symptoms; a circumstance which 
not very unfrequently occurs. The same observation, I believe, 
is applicable to the pulse; and when both these favorable symp- 
toms concur, that is, when the tongue is moistcr and cleaner, and 
the pulse less frequent and softer, than the severity of other 
symptoms would lead us to expect, we commonly see the patient 
recover, though the general indications of danger may be ex- 
tremely great." 2 "It is a consoling symptom," says Hilden- 
brand, "when the tongue, which was before dry and parched, 
becomes in the least moist and supple." 3 

Amongst the circumstances to be considered, in the prognosis 
of individual cases, are the amount and the character of the erup- 
tion, the danger of the disease being somewhat in proportion to 
the abundance and the dark color of the spots. Dr. Henderson 
found the mortality amongst those with an abundant eruption to 
be one in five ; while amongst those with a scanty eruption, it was 

1 Trans, of Phys. of Ireland, vol. i. p. 296. 

2 Succinct Account, etc., p. 43. 3 Gross's Hildenbrand, p. 107. 



270 TYPHUS FEVER. 

one in eight and a half, nearly. Of Dr. Stewart's one hundred 
and thirty-nine cases, the eruption was universally copious in 
ninety-six, and the rate of mortality was one in five ; it was parti- 
ally copious in thirty-two, and the rate of mortality was one in six 
and four-tenths ; it was scanty in eleven, amongst whom there 
was only one death. Of fifty-nine cases, wherein the eruption 
was light-colored, the deaths were one in twelve, nearly ; while of 
eighty cases, wherein it was dark-colored, the deaths were one in 
four nearly. 1 

Dr. Henderson found, at the Royal Infirmary of Edinburgh, in 
1838 and 1839, that subsultus tendinum, to any considerable 
extent, was almost always followed by death. 2 

Dr. Graves, in a paper published in the Dublin Journal for 
July, 1838, speaks of contraction of the pupil as a very unfavor- 
able sign in typhus. He says : "In fever with cerebral disease, 
one of the most alarming symptoms is marked contraction of the 
pupil ; and were I called to a case in which every other symptom 
was favorable, but great contraction of the pupil was present, I 
would say that it was a case of extreme danger. A tendency to 
even moderate contraction of the pupil is a very dangerous symp- 
tom in typhus ; but a pupil extremely and permanently contracted, 
or, as it has been called, a pinhole pupil, is or used to be a fatal 
sign." 

Heat of the skin, according to the observations of Dr. Cheyne, 
would seem to be rather a favorable indication than otherwise. 
He found that, amongst two hundred and fifty patients who were 
admitted to the Hardwicke Fever Hospital in the spring and 
summer of 1817, and in whom the temperature of the skin was 
ascertained on the day of admission, the rate of mortality was 
larger in those where the temperature was low than in those 
where it was high. Amongst eighty-three of these patients, in 
whom the temperature ranged from 98 deg. to 100 deg. Fah., 
inclusive, there were seven deaths, or one in twelve, nearly; 
amongst one hundred and twenty-seven, in whom the temperature 
ranged from 101 deg. to 104 deg. Fah., inclusive, there were 
five deaths, or one in twenty-five ; and amongst forty, in whom 
the temperature ranged from 105 deg. to 109 deg. Fah., inclusive, 

1 Edin. Med. and Surg. Journ., Oct. 1840. 

2 Ibid., vol. Hi. p. 434, Oct. 1840. 



PROGNOSIS. — HEAT OF SKIN. 271 

there was only a single death. "It was not uncommon," says 
Dr. Cheyne, "to find the thermometer gradually rising from 98 
or 99 deg. to 102 or 103 deg., or even higher, while the severity 
of the disease was abating; and, on the other hand, we frequently 
observed the temperature declining while the patient was getting 
worse ; thus the patient was often in great danger when the tem- 
perature of the body did not exceed 98 deg. In some instances, 
for a day or two before death, the mercury did not rise above 96 
or 95 deg. Indeed, in severe cases, after the temperature fell to 
par or below it, and that without any critical effort, we con- 
sidered its rising again as a favorable change. In examining the 
disordered state of the vital functions, he adds, during the summer 
of 1817, with a view to the prognostics of continued fever, we 
derived more information from the state of the breathing than 
from the pulse, and more from the pulse than from the tempera- 
ture of the body." 1 

1 Dub. Hosp. Reports, vol. ii. p. 13, el scq. 



272 



CHAPTER VIII. 

DIAGNOSIS. 

I cannot conclude this Essay on Fevers, without taking notice of the very great 
difference there is between the putrid malignant and the slow nervous fever ; the 
want of which distinction, I am fully persuaded, hath often been productive of no 
small errors in practice, as they resemble one another in some respects, though 
very essentially different in others. John Huxham. 

It is plain that there are at least two species of continued fever, both in Europe 
and this country, and further researches may very possibly show more. 

James Jackson. 

Typhus fever may be confounded with various other diseases ; 
with pernicious intermittent or remittent fever, with some cere- 
bral affections, with typhoid pneumonia. The most important 
point, however, in connection with its diagnosis, is that which 
refers to its relations to typhoid fever. It may be remembered 
that, in my observations upon the general diagnosis of the latter 
disease, I alluded to this subject, and expressed the opinion that 
the two affections constituted radically dissimilar fevers, with 
the further remark that this question could be best considered 
after the natural history of both diseases had been given. We 
are now prepared to enter upon this particular matter, and to 
establish, as far as this can be done, the differential diagnosis of 
the two fevers. There is, however, one preliminary remark which 
ought to be made here, and that is, that even if we should come 
to the conclusion, as a question of strict scientific and philoso- 
phical nosology, that these two affections are essentially and fun- 
damentally alike ; that they are forms _merely of one individual 
disease, it would still be hardly less important that we should be 
able to distinguish between them as forms or varieties of disease. 
In a practical point of view, the necessity of an accurate diag- 
nosis is not removed, even by the conclusion which I have sup- 
posed. These forms of fever, if we choose so to consider them, 
are still so distinctly marked ; they differ, in many respects, so 



DIAGNOSIS. — SYMPTOMS. 273 

constantly and so widely from each other, that their diagnosis is 
none the less important than it would be under the other suppo- 
sition, that they are essentially dissimilar diseases. After point- 
ing out their principal points of resemblance and of dissemblance, 
I will endeavor to exhibit, as fully and as faithfully as I can, the 
present state of the question in regard to their identity or non- 
identity, by a reference to the opinions and the investigations of 
those observers who have paid especial attention to this subject, 
constituting as it does one of the most interesting and important 
which is now occupying the attention of medical men. 

Sec. I. — Symptoms. In their mode of access, typhoid and 
typhus fevers, in many instances, very nearly resemble each other. 
It is pretty evident, however, that, as a general rule, the access 
of the disease is more gradual in the former than it is in the 
latter : typhoid fever creeps on treacherously and obscurely more 
frequently than typhus does ; and the latter makes its onset sud- 
denly^ and without any lingering premonitions, more frequently 
than the former does. The seizure of the typhoid fever, in grave 
cases, is much more frequently accompanied with abdominal pain 
and diarrhoea than is that of typhus. 

The chief difference between the two diseases, in regard to the 
strictly febrile symptoms, consists in the more pungent and burn- 
ing heat of the surface which characterizes typhus. Perhaps it 
is more frequently the case, also, in this disease than in ty- 
phoid fever, that the temperature of the skin falls manifestly 
below its natural standard as the febrile excitement declines. I 
am not aware that there is anything in the chills, or in the cha- 
racter of the pulse, to distinguish the two fevers. Perhaps the 
latter is more uniformly soft and compressible in typhus than in 
its related disease, and Dr. Gerhard found it more rarely bis- 
feriens, as it is called. 

The odor from the body seems to differ in the two diseases. In 
typhoid fever, when perceived at all, it is usually in the latter 
period of grave cases, and is then of a stale, cadaverous charac- 
ter ; in typhus it is pungent and ammoniacal, more common and 
more striking. 

The thoracic symptoms are subject to greater variety in typhus 
than in typhoid fever. In some seasons, they are frequent and 
well marked ; in others, they are nearly wanting. In the former 
18 



274 TYPHUS FEVER. 

disease, they consist generally of dulness on percussion, and 
feebleness of the respiratory murmur over the lower and back 
parts of the chest, and of loose mucous rhonchi ; in the latter, of 
dry, sonorous, or sibilant rhonchi. The cerebral respiration is 
common to both fevers. 

There is a pretty close correspondence in the number, the se- 
verity, and the constancy of the nervous symptoms in the two 
diseases. Taking in all grades of severity, they may be some- 
what more constant and prominent in typhus than in typhoid 
fever ; the pain in the head may be more intense and distressing ; 
the stupor may be more marked ; the morbid sensibility of the 
surface seems to be more common and striking ; and the prostra- 
tion of muscular strength, on the subsidence of the febrile symp- 
toms, is more invariable and profound. 

There is one other difference in regard to the existence of 
which I think there can be no reasonable doubt. The nervous 
symptoms in typhoid fever almost always creep on more stealthily 
and gradually than they do in typhus. This is especially true of 
the dulness and stupor. In the latter disease, this symptom is 
generally more marked and profound at the commencement than 
it is in the former. 

In the abdominal symptoms of the two diseases there are nu- 
merous and important differences. In typhoid fever, where the 
affection is at all severe, there is generally spontaneous diarrhoea, 
with liquid, yellowish, ochre-colored stools; in typhus, there is 
commonly constipation ; and the stools, when procured by purga- 
tives, are often dark, slimy, or pitchy, and offensive. Hemor- 
rhage from the bowels is not unfrequent in the former ; it hardly 
ever occurs in the latter disease. Abdominal pains are often 
present in both fevers, but in the former they almost invariably 
accompany the diarrhoea ; in the latter they are attended by con- 
stipation, and are relieved by cathartics. In the former they are 
more frequently confined to the right iliac region, accompanied 
by tenderness on deep pressure, and gurgling, than in the latter. 
Tympanitic distension of the abdomen is very common in typhoid 
fever ; it is very rare in typhus. 

The cutaneous eruptions, characteristic respectively of the two 
affections, are very unlike in many respects. In typhoid fever, 
the spots are pretty uniformly oval or circular, varying but little 
in size ; often distinctly though slightly elevated ; readily dis- 



DIAGNOSIS. — LESIONS. 275 

appearing under pressure ; generally, not very numerous ; con- 
fined, for the most part, to the skin of the chest and abdomen ; 
and of a bright rose color. In typhus, they are more irregular 
in their shape and size ; not elevated above the adjacent skin ; 
partially disappearing under pressure, or not at all ; often abun- 
dant, and even confluent ; in many cases occupying the skin of the 
extremities as well as that of the entire trunk ; and usually of a 
duller and more dusky color than in the former disease. Not un- 
frequently, also, they consist of true petechia, or cutaneous ecchy- 
moses, which in fatal cases persist after death. The average 
period of their appearance seems to be rather earlier in typhus 
than in typhoid fever. The dingy color of the skin, the dusky 
suffusion of the face, and the dark injection of the conjunctiva, 
are, to a considerable extent, peculiar to typhus. Such are the 
principal points of likeness, and of unlikeness, in the symptoms 
of these two diseases. I shall now institute a similar comparison 
between their respective lesions. 

Sec. II. — Lesions. There are some differences in the patho- 
logical alterations which are found in the thoracic organs in the 
two fevers. 

The differences in the abdominal lesions in the two diseases 
are very striking and constant. They arc so well marked, and 
so invariable, that they are easily stated. In typhoid fever, there 
is a peculiar and constant alteration of the elliptical patches of 
the ileum, consisting of various degrees of thickening, changes of 
consistence and color, and especially of ulceration. In typhus, 
these plates are very rarely altered, and when so at all, only to a 
very trifling extent. In typhoid fever, the isolated follicles both 
of the small and the large intestines are found to have undergone, 
in many cases, the same changes that occur in the aggregated 
follicles ; in typhus, they are in a healthy condition. In the for- 
mer disease the mesenteric glands, corresponding to the altered 
and ulcerated follicles, are reddened, softened, and augmented in 
volume ; in the latter they are unchanged in any respect. The 
large intestines are usually more or less distended with flatus in 
typhoid fever ; they are not so in typhus. The spleen is enlarged 
and softened in a considerable proportion of cases of both dis- 
eases, but these changes are greater and more frequent in the 
former than in the latter. Alterations in the thickness, color, 



276 TYPHUS FEVER. 

consistence, and so on, of the mucous membrane of the stomach 
and intestines are frequent but not invariable in both affections ; 
there is nothing of any diagnostic value in their differences. 

Sec. III. — Causes. In connection now with the causes of these 
fevers, there are several circumstances in which they differ- very 
considerably from each other. Typhus, although^ occurring most 
frequently in early life, is not so exclusively confined to this period 
as typhoid fever is. The former attacks individuals more than 
forty years old much oftener than the latter does. Recency of 
residence in any given place, although it seems to favor the oc- 
currence of typhus, does so much less powerfully and manifestly 
than of typhoid fever. The unknown causes of the latter disease 
connected with locality are less circumscribed, geographically, 
than those of the former ; at any rate, they seem to be more con- 
stantly and uniformly present over more extensive regions of the 
earth. In other words, typhoid fever is widely and continually 
prevalent in many places where typhus is very rarely if ever 
seen. The sporadic character of the former is more marked and 
evident than that of the latter. Typhus prevails more frequent- 
ly in an epidemic form than typhoid fever. The latter disease 
may be to a certain extent, and under certain circumstances, con- 
tagious ; but it is much less evidently and decidedly so than the 
former. The connection of crowded, filthy L and poorly ventilated 
apartments, with .the origin and propagation of typhus, is more 
manifest and unequivocal than with those of typhoid fever. 

This latter point deserves to be much more strongly and em- 
phatically stated than it was as above in my first edition. It 
seems to me to constitute a broad, unequivocal, and most striking 
difference between the two diseaes. Typhus fever is very inti- 
mately connected, in its etiology, with crowding, impure air, filth, 
and poverty ; it is, to a very great extent, dependent upon these 
causes for its primary origin. There is no point in its natural his- 
tory more positively settled than this. Many of the British writers 
allege that the entire removal of these causes would exterminate 
the disease. Now all this is entirely otherwise, so far as typhoid 
fever is concerned. I do not mean to say that crowding, impure 
air, filth, and destitution may not sometimes give rise to typhoid 
fever, and favor its prevalence, although there is very little evi- 
dence if any that they ever act in this manner. But I do mean 



DIAGNOSIS. — DURATION. — EFFECTS OF REMEDIES. 277 

to say that, as a general rule, the disease is in no way and in no 
degree dependent upon these causes. In a vast majority of in- 
stances it is entirely impossible to trace any connection between 
them ; nay, more than this, it is entirely manifest that there is no 
such connection. The poison of typhus fever is generated in a 
stagnant and depraved atmosphere, rank with the thick corruptions 
of concentrated emanations from the living human body ; — the 
poison of typhoid fever, like that of epidemic cholera, and like 
that of scarlatina, comes we know not whence : it is generated 
as readily amidst cleanliness and purity as amidst filth; and it 
floats as freely in the fresh breezes under the open sky, as in the 
close and stagnant atmospheres of crowded cabins and lanes. 

Sec. IV. — Duration. The average duration of typhus is con- 
siderably less than that of typhoid fever, and death from the 
former disease occurs in many cases earlier than from the latter. 
The termination of the disease by a more or less well-marked 
crisis is also much more common in the former than in the latter. 

Sec. V. — Effects of Remedies. Finally, it is very evident, I 
think, that these two diseases differ from each other in the effects 
which are produced upon them by remedies. The immediate 
influence, for instance, of treatment, is much more obvious in 
typhus than it is in typhoid fever. General or local bleeding, 
when it is indicated, is more uniformly followed by mitigation or 
removal of local pain, especially of that of the head. So the 
administration of stimulants and tonics, under circumstances that 
call for them, is more frequently followed by a strong and mani- 
fest impression upon the morbid actions than is often seen in 
typhoid fever. It is pretty clear also that, as a general rule, 
typhus requires a more tonic and supporting treatment than the 
latter disease. M. Bouillaud may have failed to show that ty- 
phoid fever is more successfully treated by repeated bleedings, 
general and local, even at periods of the disease somewhat ad- 
vanced, and independent of any special local indication, than by 
any other plan ; but he has at least demonstrated that this treat- 
ment may be borne with a good degree of impunity. We rarely 
hear of the sudden and often fatal sinkings, and collapses, which 
have so frequently followed a single moderate abstraction of blood 
in the middle and later stages of typhus. 



278 TYPHUS FEVER. 

Sec. VI. — Historical. If this alleged and well-defined differ- 
ence between typhoid and typhus fevers really exists ; if these two 
diseases are radically and fundamentally diverse, and unlike 
each other, and if the diagnosis between them can be generally 
established, it becomes a matter not only of scientific interest, 
but of great practical moment, for us to inquire how far this dis- 
tinction is recognized, either in form or in fact, by the leading 
and classical British writers, who have long been, and who still 
continue to be, to a very great extent at least, our guides and 
authority on the subject of continued fever. What do they mean 
by the terms typhus fever, common continued fever, slow nervous 
fever, and so on ? Do they describe a single disease, essentially 
identical in its nature, and differing only in its form, under these 
several appellations ? If so, what is this disease ? Is it the, typhus 
fever, or is it the typhoid fever of this book ? On the other hand, 
do they describe distinct and separate diseases under these several 
appellations ? If so, what are these diseases ? Are they typhoid 
and typhus fevers, or are they something else ? Certainly, I need 
not say how necessary it is to all sound science, and to all suc- 
cessful or even safe practice, that we should understand each 
other upon this primary and fundamental point of diagnosis. 
Certainly, I need not say what contradictions and what inex- 
tricable confusion must inevitably grow out of the want of this 
understanding. In order to determine as far as may be the 
questions above indicated, I will briefly examine the opinions and 
observations of some of those British authors whose works are 
most generally in the hands of our own practitioners, and whose 
writings have most extensively influenced their doctrines and 
their practice. Amongst these I may mention particularly 
John Armstrong, Southwood Smith, and Alexander Tweedie. 

In Dr. Armstrong's u Practical Illustrations," there is a great 
deal of gratuitous generalization, and of loose diagnosis ; but he 
nevertheless admits, very distinctly, the existence of two distinct 
forms of fever. One of these he calls typhus fever ; and the 
other common continued fever. He uses the term typhus, he 
says, not, as has often been the case, to designate the combination 
of malignant symptoms which may take place in the last stage of 
any acute disease, but/ "to denote a specific disease, that, like the 
epic poem of ancient critics, has a beginning, a middle, and an 
end." The common continued fever of Dr. Armstrong is, I 



DIAGNOSIS. — HISTORICAL. 279 

think, the ty2)hoid fever of Paris, and of New England. Some 
of the leading and prominent distinctions between the two 
diseases, already so fully pointed out in the foregoing pages, can 
hardly fail of being recognized in the following extract: " The 
disturbance of the sensorial functions, and the prostration of the 
moving powers, are remarkably characteristic of true typhus. In 
the most frequent forms of the common continued fever, the 
patient has uneasiness in the head ; but he has a bright eye, and 
a countenance indicative of no mental depression or despondency; 
and he lies in a position which displays some command of muscles, 
and can move about the bed, or get up, with a tolerable effort. 
On the contrary, in genuine typhus, the eye always wants anima- 
tion ; the countenance has a dull, wearied, depressed, and often 
desponding expression, and the patient lies in a comparatively 
relaxed position, and moves himself more languidly, almost like 
one worn out by loss of sleep, and from some unusual fatigue. 
In the common continued fever, the patient commonly has not 
much inaptitude of mind, often answers questions readily, and in 
a pretty firm voice, without much increased agitation of the 
breathing; whereas, in typhus, the answers are mostly given 
with languid slowness and reluctance, and much speaking ob- 
viously disturbs the respiration. In the common continued fever 
the skin is generally of a brighter red than natural, especially on 
the cheeks ; on the contrary, the skin is always more or less of a 
dusky color in typhus, and an admixture of it may be best ob- 
served in the flush of the face. This duskiness of the skin is one 
of the proper symptoms of typhus, and seems to arise from some 
change in the constitution of the blood, which I have almost 
invariably seen darker than in ordinary fevers. In the worst 
cases, the duskiness increases in the progress of the disease, and 
lessens in those that assume a mild aspect. So very characteristic 
is this cutaneous duskiness, that I think I could distinguish typhus 
by it at any time, if two patients were presented to me, the one 
laboring under that disease, and the other under the common 
continued fever. In typhus, the tongue has an early tendency 
to become brown and dry ; in the common continued fever it is 
always white, and often even somewhat moist for the first week ; 
in typhus, the pulse is variable as to force and frequency, but it 
is seldom very resisting to pressure ; but in the common continued 
fever, it mostly resists firm pressure of the finger, from the freer 



280 TYPHUS FEVER. 

stroke of the heart. The above remarks are certainly most 
appropriate to the first and middle stages of the ordinary in- 
stances of typhus, and of the common continued fever; for, in 
the last stage of both, many of the symptoms so approximate as 
to make them more nearly resemble each other." 1 Dr. Armstrong 
also speaks of the peculiar odor from the body in typhus fever, of 
the appearance of petechiae, and of the frequency and gravity of 
pulmonic complications. Amongst the occasional symptoms of 
the common continued fever, he mentions epistaxis and diarrhoea ; 
and in most cases, he says death occurs at the end of the second 
or middle of the third week, but sometimes later. Now when it 
is remembered that the diagnosis between this common continued 
fever of Dr. Armstrong, and many local inflammations, was but 
very imperfectly established when his book was written; J;hat its 
characteristic features had been but partially ascertained; that 
other diseases must necessarily often have been confounded with 
it, we shall have no difficulty, I think, in coming to the conclu- 
sion that, with these qualifications, the disease described by Dr. 
Armstrong as the common continued fever, is identical with the 
typhoid fever of the present day, and that his typhus fever is the 
typhus of the present day. 

Dr. Armstrong thinks that there is a third form of fever, occa- 
sioned by the crowding together of a great number of persons in 
filthy and close apartments, differing from both the preceding 
fevers. His notice of it is too short and imperfect to enable one 
to judge of the correctness of this opinion, but the disease which 
he describes was probably a form of typhus. 

Dr. Southwood Smith denies the existence of more than one 
continued fever. To the several forms and varieties of this single 
fever, depending upon degrees of severity and complications, 
he applies different terms; merely, however, as a matter of 
convenience. "The more we investigate the subject," he says, 
"the more satisfied we shall become that continued fever is one 
disease, and only one, however varied or even opposite the aspect 
it may present ; but that it differs in intensity, in every different 
case ; and that this, and this alone, is the cause of the different 
forms it assumes." 2 

1 Practical Illustrations of Typhus Fever, etc. By John Armstrong, p. 234, et 
seq. 

2 A Treatise on Fever. By Southwood Smith, M. D., Boston, 1831; p. 41. 



DIAGNOSIS. — HISTORICAL. 281 

Notwithstanding this opinion of Dr. Smith, an attentive study 
of his book, with our present knowledge upon this subject, will 
lead us, I think, to the conclusion that the two diseases which I 
have described, the typhus and the typhoid fever, both fell under 
his observation, and both helped to furnish the materials for his 
work ; although he failed, as his predecessors and contemporaries 
had done, to discover and to distinguish clearly the differences 
between them. It must, however, be added that his histories of 
the several varieties of fever are not sufficiently full and accurate 
to enable us always to make a satisfactory diagnosis. His descrip- 
tions are glowing and vivid enough, too much so, perhaps ; but 
they are not diagnostic, they are not discriminating, they are 
not complete. Like those of almost all English writers upon 
fever, they are not pure ; they are mixed up and corrupted with 
a priori and hypothetical explanations and interpretations of the 
symptoms. 

His synochus mitior seems to be a mild form of typhus, although 
it is impossible to speak with any confidence, from his description. 
The same remarks may be made, excepting as to the severity of 
the disease, of his synochus gravior, with subacute and with 
acute cerebral affection, and with thoracic affection. His syno- 
chus gravior, with abdominal affection, corresponds more nearly 
to typhoid fever. Some of the cases included in this subdivision 
certainly belong to the latter disease. His several varieties of 
typhus, corresponding to those of synochus, and excepting that 
with abdominal affection, are pretty evidently, for the most part, 
made up of cases of true typhus. His typhus mitior, with ab- 
dominal affection, looks more like typhoid fever. 

Now, taking the evidence derived from the symptomatology 
alone, in these descriptions by Dr. Smith of his several forms 
and modifications of continued fever, one thing at least we may 
look upon as settled. If, on account of the incompleteness and 
vagueness of Dr. Smith's general and particular histories of the 
disease, we are not justified in deciding positively that the two 
distinct fevers, as I have described them, were both present in 
the London Fever Hospital, we may with entire confidence assert 
that these histories contain no evidence whatever that such was 
not the case. So far as the evidence derived from this source 
goes at all to settle the question, aided and interpreted as it now 
is by our present knowledge, it goes to show that both typhoid 



282 TYPHUS FEVER. 

and typhus fever, but principally the latter, constituted the dis- 
ease which Dr. Smith describes; and this conclusion we shall 
find singularly corroborated by an examination of his cases illus- 
trative of the pathology of the disease. 

His general description of the lesions found after death is too 
loose and imperfect to be much relied upon. He speaks of the 
dusky color of the skin, the large purple petechiae, and the dark 
color of the muscles and the internal viscera. The brain is 
described as usually morbid, either increased vascularity of its 
membranes and substance or serous effusion constituting the 
most common alteration. We may, however, well feel the ne- 
cessity of caution and skepticism, when we find it stated, as it is, 
that "the pituitary gland is very constantly softened, and often 
in a state of suppuration." The mucous membrane of the bron- 
chial tubes was very generally thickened, and of a dark red color. 
The lower portion of the small intestine is said to have been found, 
in many cases, more or less extensively diseased; its mucous 
membrane sometimes only reddened and vascular, and at others 
the seat of ulcerations. These ulcerations, with alterations in the 
mesenteric glands, seem to have been identical with the entero- 
mesenteric lesion which I have described as characteristic of ty- 
phoid fever. In a large number of cases, on the other hand, 
the intestine is said to have been free from disease. Now, the 
point to which I wish more particularly to refer, illustrative of the 
question before us, is this ; the average age of the patients con- 
stituting the two classes of cases; those which did and those which 
did not exhibit, after death, the peculiar lesion of the elliptical 
plates found in typhoid fever. I find, for instance, that there are 
thirty-five cases reported of fever with prominent cerebral affec- 
tion, and with absence of intestinal ulceration ; and that the 
average age of these cases is thirty-four years. Of these patients 
there were thirteen who were over thirty-five years of age ; ten of 
them were as high as fifty, and the oldest was sixty-five. There 
are eight cases reported of fever with prominent thoracic affection, 
and with no ulceration of the intestine. The average age of these 
cases is somewhat more than thirty-six years. There are three 
cases reported of fever with prominent abdominal symptoms, but 
without ulceration of the ileum, and the average age of these is 
forty-five years. There are eight cases reported of mixed disease, 
without ulceration, the average age of which is twenty-two years 



DIAGNOSIS. — HISTORICAL. 283 

and a half. The average age of these fifty-four cases is about 
thirty-three years. I find, furthermore, forty cases reported 
wherein the intestinal ulcerations characteristic of typhoid fever 
were present; and the average age of these cases is twenty-two 
years and a third. Only four of them were over thirty-five, and 
the oldest was fifty years of age. The hearing of this result 
upon the question of the existence of typhus and typhoid fevers 
amongst Dr. Smith's cases, and of the diagnosis between them, 
is too obvious to require any further remark. 1 

Dr. Alexander Tweedie's Clinical Illustrations of Fever were 
published in 1830. This work is more fragmentary in its cha- 
racter, and less systematic, than the treatise of Dr. Smith ; but it 
bears many marks of sound judgment and careful observation. 
Dr. Tweedie seems to be very strongly impressed with the fact 
that different and diverse fevers prevail in London; but he has 
failed to point out, with any degree of accuracy or complete] 
their distinguishing characteristics. His work, like that of Dr. 
Smith, is thus rendered almost valueless, by the fatal and funda- 
mental defect of a want of all clear and well-defined diagD 
This is true in relation not only to the separate kinds of fever, 
but also to other and widely different diseases. Thus, under the 
head of continued fever, we find many cases which are mani- 
festly not fevers of any kind. These are instances of peritonitis, 
pneumonia, phthisis, and so on. Under these circumstances, and 
from such imperfect data, it would be worse than idle to attempt 
to settle the important question of the kind and character of the 
fever, or the fevers, which are described by Dr. Tweedie. I wish 
merely to remark that an examination of his cases in reference 
to their average age, furnishes the same singular corroboration of 
the correctness of the opinion which I have given in regard to 
the existence amongst them of both typhoid and typhus fever 
as has already been deduced from a similar examination of those 
of Dr. Smith. For instance, of fifteen cases which, as Car as I 
can judge, seem to have been cases of fever, and in which there 
was no intestinal ulceration, the average age was about forty 

1 Dr. Eeid's one hundred fatal cases have already been spoken of. There were 
only six of thein which presented the lesion of typhoid fever ; the average age of 
these six cases was twenty-five years: the average age of the one hundred cases 
was thirty-six years and a third; seventy-seven were over thirty, and forty-two 
were over forty. — Edin. Med. Journ., Aug. 1842. 



284 TYPHUS FEVER. 

years ; while of sixteen other cases, in which the lesion charac- 
teristic of typhoid fever seems to have been present, the average 
age was less than twenty-six years. 

By some of the older British physicians, however, amongst 
whom may be mentioned, especially, the incomparable Huxham, 
the difference between these two forms of fever was distinctly no- 
ticed. I have already given an extract from this writer's Essay 
on the Difference between a Slow Nervous and a Putrid Malignant 
Fever ; in which, considering the time when it was written, and 
the comparatively imperfect study of diagnosis which was then 
common, the peculiar features of the two diseases are very well 
delineated. 

In a letter from Dr. Darwin to Dr. Lettsom, dated Derby, 
October 8, 1787, the following passage occurs: "If your> Society 
proposes questions, I should wish to offer for one, ' Whether the 
nervous fever of Huxham (or fever with debility, without petechia 
or sore throat, or flushed countenance, or pungent heat), be the 
same as the petechial fever, or jail fever ?' The former of these, 
viz., the nervous fever of Huxham, prevails much over all the 
country at this time." 1 

Dr. Vaughan, also, of Leicester, in a letter to Dr. Lettsom, 
dated July 27, 1783, in reference to the same subject, observes : 
"There is surely a peculiarity in the species of fever you had 
the goodness to send me an account of, protracting itself to such 
a length as thirty-five or forty days : it certainly agrees very 
much with Huxham' s Febris Nervosa, which, notwithstanding 
Dr. Cullen, is a very different disease to the Febris Carcerum, 
in its attack, progress, termination, and cure." 2 

Contemporary with these authorities, and inferior certainly to 
none, is that of Sir John Pringle, who very distinctly recognizes 
the difference between jail fever or typhus, and the low nervous, 
miliary, or typhoid fever. "In the description," he says, "I 
have endeavored to distinguish them," i. e. malignant or pestilen- 
tial fevers, " from all others, as far as I could do it in distempers 
whose symptoms are so much alike. The nervous fevers are 
frequently accompanied with miliary eruptions, which have no 
resemblance to the petechial ; nor have I ever happened to see 

1 Life and Correspondence of Dr. Lettsom, vol. iii. p. 118. 
3 Ibid., vol. iii. p. 161. 



DIAGNOSIS. — HISTORICAL. 285 

miliary eruptions in this malignant kind." 1 In reply to some 
strictures of De Haen, he says, still more explicitly : " I have 
never considered the jail or hospital fever, and the miliary fever," 
meaning the low nervous, or typhoid, " as similar ; and indeed I 
may venture to say that, as the symptoms of the two are so much 
unlike, they ought to be treated as different in specie ; and, con- 
sequently, that neither the theory nor the practice in the one 
ought to be regulated by analogy from the other." 2 Again, he 
says : " I have, therefore, all along considered the jail or hospital 
fever (in regard to others, that commonly occur in these parts), 
as a fever sui generis, at least as different from either the scarlet, 
the miliary, or any other eruptive fevers, which are known." 3 

The strictures alluded to above, by De Haen, had reference 
particularly to the treatment of fever, by Huxham and Pringle. 
De Haen charged these great British observers with bad practice, 
with a too stimulating and incendiary method in the management 
of fever. Pringle, in his reply to De Haen, says, expressly, that 
the fever treated by the latter at Vienna was of a different kind 
from that treated by himself; and in a note to this reply, he 
makes the following very interesting remarks in regard to the 
dissimilarity of the cutaneous eruption in the two diseases. 
"After publishing what is above, relating to the distinction which 
I conceived was to be made between De Haen's petechia; and 
mine, I was confirmed in my opinion by Dr. Huck, who in the 
year 1763 was at Vienna, and was favored with admittance into 
all the hospitals there, and in particular had the satisfaction of 
attending Dr. De Haen himself, and seeing with that celebrated 
physician, some of his patients in that very fever which he calls 
petechial. Dr. Huck examined those spots in Dr. De Haen's 
presence, and assured me that they had hardly any resemblance 
to those which I have called petechial, and which he himself had 
so often seen in the hospitals of the army ; but that they were so 
like flea-bites, that he was apt to believe that one must be often 
mistaken for the other." 4 Let me add, here, that I do not know 
anything in the annals of medical polemics, imbued with a finer 

1 Observations on the Diseases of the Army. By Sir John Pringle. Philad. 
ed., p. 298. 

2 Ibid., p. 384. 3 Ibid., p. 385. 

4 Observations on the Diseases of the Army. By Sir John Pringle. Philad. 
ed., p. 390. 



286 TYPHUS FEVER. 

temper, or a more philosophical spirit, than this reply of Pringle 
to De Haen. It is every way equal — and there is no higher 
praise than this — to Louis's defences against the attacks of 
Broussais and Bouillaud. In place, or out of place, I cannot 
forego the pleasure of gracing a page of my book with the fol- 
lowing golden words from the reply of Pringle. " In fine, Dr. 
De Haen may be assured, that the regimen which I propose stood 
at first on no other foundation than experience, after my having 
seen the bad effects of a contrary method, whether by too large 
or too frequent bleedings in the beginning, or by giving hot 
things too early, in order to raise the pulse when it began to sink, 
or to force a crisis before the common period of the disease. 
Some of the medicines are superfluous, but I am pretty sure 
that none of them are hurtful. * * * But having once got into 
a method, which brought about as many cures as seemed other- 
wise consistent with the circumstances of my patients, lying in a 
foul air, amidst a constant noise, and often neglected by the 
nurses, I did not attempt to reduce my practice to more - sim- 
plicity than what is mentioned. Yet, whatever confidence I may 
have in the directions which I have published, I am still ready 
to alter any part of them, upon a fair representation from those 
who have had equal opportunities with myself of seeing and 
treating this fever. But to oppose either mere theory or ana- 
logy from other fevers, where the similarity is so disputable, or 
to oppose some general maxims from Hippocrates or Sydenham 
to the observations which I have offered as the result of a long 
and painful experience in a distemper that no physician could 
well know but in such circumstances as mine, is a manner of 
writing, I must say, more fitted for disputations in a school of 
medicine than for the instruction of a practical physician." 1 

Dr. Macbride, of Dublin, says that the " Putrid Continual 
Fever j before Dr. Langrish's 2 time, was confounded with the nerv- 
ous ; but though both nervous and inflammatory fevers, towards 
the close, often show that by that time the crasis of the blood is 
destroyed, yet we are not to confound them with this," the putrid 
continual, "wherein, from the very beginning, there is some pecu- 

1 Observations on the Diseases of the Army. By Sir John Pringle. Philad. 
ed., p. 395. 

2 "The Modern Theory and Practice of Physic, by Browne Langrish, M. D., 
Lond. 1735." 



DIAGNOSIS. — HISTORICAL. 287 

liar acrimony, which dissolves the bond of union among the in- 
sensible particles, and allows them to run into combinations oppo- 
site to the mild, smooth, and emollient nature of blood in the 
healthy state." 1 

Dr. Willan, in speaking of the contagious typhus of London, 
in 1799, says: " To this contagious fever, alone, Dr. Cullen ought 
to have applied the denomination of typhus mitior ; he has impro- 
perly comprised under it the slow or nervous fever, described by 
Huxham and Gilchrist, which may rather be considered as a spe- 
cies of hectic, and is not received by infection." 

Dr. James Sims, of the county of Tyrone, Ireland, although 
disposed to doubt the existence of the distinctions between the 
slow nervous and the putrid fever, insisted upon by Huxham, still 
says : "I would not by this be understood to mean that there is 
no difference in reality between a low nervous fever, as it is called, 
and a putrid malignant one ; I am well aware that there is ; but 
am afraid that, in the last stage of the nervous one, as described 
by Dr. Huxham, a change is brought about by his treatment of 
it that he little suspects, which is its degenerating into a truly 
putrid malignant fever in nothing distinguishable from the other 
described under that appellation." 3 

In the 4th volume of the Edinburgh Medical Essays and 
Observations, 1734, there is an Essay on Nervous Fevers, by Dr. 
Ebenezer Gilchrist, of Dumfries. The disease described by Dr. 
G. is evidently typhoid fever. " I take this fever," he says, "to 
be very different in its nature and changes from other fevers." 

In a continuation of the same essay, in the 6th volume, Dr. G. 
thus describes the disease. "The fever runs out to the twentieth, 
twenty-fifth, thirtieth, and sometimes to the thirty-fifth day. The 
symptoms upon seizure are generally such as are common to all 
fevers — coldness, trembling, and frequent alternations of heat 
and cold, nausea, headache, and vomiting ; while at other times 
it draws on more insensibly. * * * From the seventh or eighth 
day, sooner or later, a delirium comes on, which is constant, and 
lasts through the fever, but for most part is not very high ; the 
tongue is black, chapped, and parched. The sick are faint, highly 

1 A Methodical Introduction to the Theory and Practice of Physic. By David 
Macbride, M. D. London, 1772, p. 324. 

2 Med. and Phys. Journ., vol. ii. p. 412. 

3 Obs. on Epid. Dis., p. 248, 1776. 



288 TYPHUS FEVER. 

dispirited, sigh heavily, and, when the fever is vehement, have a 
nervous or intercepted breathing. * * * A symptomatical loose- 
riess, or deafness, or both, accompany it to the end. What 
deserves a serious consideration, is the frequent hemorrhages or 
bloody appearances that happen. I have known them bleed four 
or five pounds by the nose in a few hours : bloody or sanious stools, 
and very fetid, are observed. * * * Seldom do they die soon in 
the disease, though it has been fatal before the fourteenth day." 
* * * " The disease, before it makes its attack, gives sufficient 
warning sometimes. Two or three weeks before they are laid 
down, they are low-spirited, inappetent, loaded, sleep ill, sigh fre- 
quently, groan involuntarily, and feel inexpressible disorder, ac- 
companied with great fear, concern, and dejection, and perhaps, 
slight alienation of mind." The essay is long and tediously 
stupid, with a priori reasonings. 

Twenty-five years ago, an interesting paper was published in 
the Edinburgh Medical and Surgical Journal, by Dr. Autenrieth, 
Jr., on the Sporadic Abdominal Typhus of Young People, ^is the 
disease showed itself in the south of Germany. The difference 
between it and the typhus is distinctly recognized ; although, as 
the author remarks, the two diseases had generally been con- 
founded. Dr. Autenrieth, Jr., says expressly, and in so many 
words, that the disease which constitutes the subject of his essay 
is essentially distinguished from typhus ; by arising independently 
of any contagion ; by the particular time of life in which it spon- 
taneously occurs ; and by the seat of the complaint being in the 
abdomen, rather than the brain. Amongst the symptoms which 
the author "enumerates, and which show very clearly its identity 
with typhoid fever, and its difference from typhus, are watery 
diarrhoea, abdominal pains, tympanites, and epistaxis. Dr. Au- 
tenrieth's sketch of the disease was written from memory, while 
he was residing in Edinburgh, and at the close of his paper, he 
refers to a more exact and comprehensive description of the dis- 
ease, to be expected from the hand of his father. "If," he says, 
in conclusion, "by the present attempt, I should be so happy as 
to excite the attention of the British medical profession to the 
knowledge and cure of this disease, I entertain the hope that, in 
a short time, the science may be enlarged, and my design com- 
pletely attained." It is not a little remarkable that the attention 
of British observers should have been especially called to this 



DIAGNOSIS. — HISTORICAL. 289 

particular subject — the distinctions between these two forms of 
fever — fourteen and sixteen years subsequent to the publication 
of Dr. Autenrieth, Jr.'s, paper, by two other young continental 
physicians — Dr. Lombard, of Geneva, in 1836 ; and Dr. Staberoh, 
of Berlin, in 1838. 

I shall now give a summary of the investigations which have 
been made, and of the opinions which have been advanced, in 
regard to this very important question, during the last few years. 

Dr. E. Hale, Jr., of Boston, in a paper on the typhoid fever 
of New England, published in the Medical Magazine for Decem- 
ber, 1833, speaks very decidedly of the want of correspondence 
between the descriptions of typhus, given by Dr. Armstrong and 
Dr. Southwood Smith, and the phenomena presented by the 
common fever of our own country. These phenomena, he says, 
are " widely different" from those enumerated by the foregoing 
writers, as characteristic of the typhus which they describe ; but 
whether this want of likeness depends upon various modifying 
circumstances connected with the prevalence of the disease in 
the two countries, or upon an " intrinsic difference' in their 
nature, he does not stop to inquire. 

The Dublin Journal of Medical Science, for September, 1836, 
contains two short letters, written by Dr. H. C. Lombard, of 
Geneva, and addressed to Dr. Graves, on the relation of the 
typhus fever of Britain to the typhoid fever of the Continent. 
Dr. Lombard had for six years been familiar with the latter 
disease in France and in Switzerland, and, in the fatal cases, had 
invariably found the peculiar lesion of Beyer's glands. On Dr. 
Lombard's arrival in Glasgow, in 1836, he was allowed by his 
friends to examine the body of a fever patient, in whom he had 
said no doubt could exist as to the presence of follicular disease. 
He was not a little astonished at finding the elliptical plates 
wholly unaltered. On his arrival in Dublin, he was again fur- 
nished with an opportunity of making two similar examinations 
— one at the Meath, and one at the Hardwicke Hospital — and 
here again he was disappointed in not finding any lesion of the 
elliptical plates. Dr. Lombard alleges that he found the symp- 
toms of the British typhus almost identical with those of the 
typhoid fever of the Continent, but he immediately proceeds to 
mention the great difference in the appearance of the eruption 
in the two diseases, or forms of disease, the frequent occurrence 
19 



290 TYPHUS FEVER. 

of typhus in old subjects, the absence of prominent abdominal 
symptoms, and its strongly-marked contagious character. He 
does not speak very positively upon the subject, but is unwilling 
to admit that the two diseases are specifically distinct. 

Dr. Lombard, on his way home, visited the Fever Hospitals of 
Liverpool, Manchester, Birmingham, and London; and on his 
arrival in Geneva, wrote a second letter to Dr. Graves, bearing 
date about one month subsequent to his first communication. At 
Liverpool, Manchester, and London, he found the same state of 
things as he had seen in Dublin and Glasgow ; prominent cere- 
bral symptoms, an abundant cutaneous eruption, infrequency of 
abdominal disorder, many patients of advanced age, and strong 
evidences of the contagious character of the fever. It does not 
appear that he witnessed any autopsies anywhere in England. 
At Liverpool, he was told that ulcerations of the ileum anol coecum 
were occasionally but by no means constantly met with, and 
that their frequency varied in different seasons. At Manchester, 
he was informed, merely, that the ulcerations of the intestines 
were by no means always to be found in the fatal cases. At 
Birmingham, he saw no patients, but was told by the medical 
attendants of the fever wards in the General Infirmary, that, in 
examinations, after death, ulcerations of the lower part of the 
ileum were always present. At the London Fever Hospital, he 
saw but very few patients, but concludes, from Dr. Tweedie's 
researches, that ulcerations in the lower part of the ileum are not 
to be found in more than one-fourth of the fatal cases, and that 
their frequency varies with different seasons; it being much 
greater in autumn than at any other period of the year. 

This constitutes the whole sum and substance of Dr. Lombard's 
personal knowledge of the typhus fever of Great Britain. In his 
second letter, he expresses, very decidedly, the opinion that there 
are two distinct and separate fevers prevalent in Great Britain ; 
one of them identical with the contagious typhus, the army and 
jail fever of the French pathologists ; the other a sporadic disease, 
identical with the typhoid fever, or dothinenteritis, of the French. 
He considers Ireland as the source of the former disease ; and 
supposes it to be carried by the Irish, in their annual migrations, 
to the several large towns and cities of the sister island. 1 In 

1 As an offset to this opinion it may be remarked that Dr. Barker, many years 
ago, attributed the great increase in the prevalence of fever which took place 



DIAGNOSIS. — HISTORICAL. 291 

Glasgow, it constitutes, he says, one-third of the total number of 
fever cases ; in Dublin, much less ; and in London, one-fourth ; 
these proportions varying in different seasons, but being greatest 
in autumn. 

Many of the suggestions contained in these letters were, at 
the time when they were made, exceedingly important ; and it 
seems somewhat singular that they should not immediately have 
received a greater degree of attention from British observers. 
The conclusions, however, in regard to the exact degree of pro- 
portion in the prevalence of the two fevers, or forms of fever, in 
different cities of Great Britain, and in regard to the exclusive 
origin of typhus in Ireland, and its subsequent diffusion through 
Scotland and England, are, to say the least of them, premature 
and gratuitous. This precipitancy of judgment would seem to 
be a prominent characteristic of Dr. Lombard's mind ; for we find 
him, in 1839, imagining that he had demonstrated the existence 
of a new disease, a true bilious fever, differing both from typhoid 
and from the bilious remittent fever, from this worthless and 
utterly inadequate evidence — the occurrence of two cases of pro- 
longed bilious vomiting and purging, one of them in a female 
seventy-four years old, the other in a female fifty-eight years old, 
both terminating fatally ; in only one of which was there an ex- 
amination of the body, and in this no apparent legion of any of 
the organs !' In the 48th volume of the Edinburgh Medical and 
Surgical Journal, there is a very interesting notice of several 
papers, by recent German writers, on the abdominal typhus of 
that country, in which the question of the identity of this disease, 
clearly and manifestly typhoid fever, with the true British typhus 
is at least admitted to be a legitimate subject of doubt, and of 
further investigation. Macculloch insists very strongly that the 
typhus mitior of Cullen, the low, nervous fever, as it is commonly 
called, is essentially different from true contagious typhus. 2 

One of the most important documents in the history of this in- 
vestigation is the paper of Dr. Gerhard's, to which reference has 
been so frequently made. The leading facts contained in that 
paper, so far as they bear upon the question before us, have already 
been embodied in the preceding account; it can be hardly neces- 

throughout Ireland, during and after the year 1810, to its introduction from the 
Continent by the return of the Walcheren troops, and in other ways. 

1 Gazette Medicale, March, 1839. - Macculloch on Marsh Fever, p. 35. 



292 TYPHUS FEVER. 

sary, therefore, to repeat them here. It is enough to say that the 
disease observed by Dr. Gerhard, and Dr. Pennock, prevailed 
somewhat extensively, there having been admitted to the hospital 
with it, between March and August, 1836, nearly two hundred and 
fifty patients: that it corresponded very exactly in its symptoms 
to the true typhus ; that it was clearly transmissible by contagion ; 
and that the elliptical plates and the mesenteric glands were 
found uniformly free from the lesion of typhoid fever. Dr. Ger- 
hard and Dr. Pennock had both been familiar with the latter 
disease, and they were struck with the wide difference between it 
and the typhus of 1836; and to them belongs the credit of having 
first fully pointed out, and clearly established, the most prominent 
and essential points of dissemblance between the two diseases. 

Dr. Staberoh, of Berlin, after four or five years' study of con- 
tinued fever in Vienna and Paris, and after passing six months 
in Great Britain, where he had extensive opportunities for ob- 
serving both typhus and typhoid fever, adopted the doctrine of 
the specific difference between the two diseases. 1 

Mr. Henry Kennedy, in a paper contained in the Dublin Jour- 
nal for March, 1838, says that while his mind was in a state of 
suspense, in regard to the conflicting opinions of the French and 
British pathologists, as to the connection between intestinal le- 
sions and continued fever, an opportunity was presented to him 
of seeing the common fever of Paris and of Geneva ; and to his 
surprise he found it in many particulars different from the typhus 
of his own country. Two years of subsequent uninterrupted 
study of the subject convinced him " that the fevers of the two 
countries are of different types, and that typhus may in the great 
majority of instances be distinguished from the gastro-enteric 
fever of the French." 

In the early part of 1839, Dr. George C. Shattuck, Jr., of 
Boston, had an opportunity of studying under favorable circum- 
stances a small number of cases of continued fever in England. 
Dr. Shattuck had been already familiar with the typhoid fever of 
Paris, where he had then recently been engaged in its investiga- 
tion, under Louis. It was at the particular request of Louis, as 
well as from his own warm interest in this very important ques- 
tion of diagnosis, that his observations were made. He saw 
thirteen cases of continued fever, at the London Fever Hospital, 

1 Dublin Journ. of Med. Science, July, 1838. 



DIAGNOSIS. — HISTORICAL. 293 

where he says, through the kindness of Dr. Tweedie the attend- 
ing physician, and of Mr. Goodfellow the resident medical officer, 
every facility for the examination of the patients and for anato- 
mical researches was afforded him. An account of these oases 
was communicated by Dr. Shattuck to the Medical Society of 
Observation of Paris. They were subsequently made the ground- 
work of an elaborate memoir of nearly seventy pages, by M. 
Valleix, which is contained in the October and November num- 
bers of the Arc?dves Generates de 31edecine, of Paris, for 1839. 
Dr. Shattuck's own history of his observations -was published in 
the Medical Examiner for February 20, and March 7, lfi 
As M. Valleix's analysis and comparison are founded entirely 
upon the cases furnished by Dr. Shattuck, it is unnecessary to 
take any further notice of the former, excepting to say that the 
author arrives at the conclusion that the typhoid and typhus 
fevers are both to be met with in England, and that they are dis- 
tinct diseases. 

Dr. Shattuck's paper contains histories, more or less complete 
and extensive, of six of the thirteen cases. The first of these 
was clearly enough identical with the typhoid fever of Paris and 
New England. The patient was twenty-two years old; and in 
addition to many symptoms common to both diseases, there were 
meteorism and diarrhoea; and on examination after death, the 
characteristic lesion of the elliptical plates and the mesenteric 
glands, although moderate in extent, WM present. Nothing is 
said in the report of this case of any cutaneous eruption. The 
second case corresponded in its most prominent features to the 
typhus fever of the Irish writers, and of Dr. Gerhard. There was 
no meteorism, and the skin of the trunk and limbs was covered 
with numerous spots, of a dark red color, imperfectly disappear- 
ing on pressure, of the size of the head of a pin or of a small pea, 
grouped together. The elliptical plates and the mesenteric 
glands were in a healthy condition. In the third case, the disease 
does not seem to have been so clearly marked. The symptoma- 
tology was rather that of typhoid than of typhus fever; but 
along with four or five lenticular rose spots on the abdomen, 
slightly raised above the surface of the skin, and disappearing on 
pressure, there were other spots grouped together, not raised 
above the surface. The history of the case is not very full. The 
fourth case was evidently enough, I think, one of typhus fever. 



294 TYPHUS FEVER. 

The abdominal symptoms were very slightly marked; there were 
redness and suffusion of the eyes, and the deep red grouped 
eruption over the skin of the body and arms. In the fifth case, 
whieh is briefly described, the diagnosis is uncertain. There 
were no abdominal symptoms, and both eruptions seem to have 
been present, as in the third case. The sixth and last case is 
reported more at length. It resulted fatally, and after six days 
of mild and damp weather, the abdominal viscera were removed 
from the body and examined. There was no appreciable alteration 
of the elliptical plates, or the mesenteric glands. Dr. Shattuck 
seems disposed to consider this case as one of typhoid fever. 
There was diarrhoea, and the abdomen was somewhat swollen. 
It was tender on pressure, but so also were the limbs. There 
were few lenticular rose spots upon the abdomen, but they 
were followed by an abundant petechial eruption, of a deep red 
color, scarcely disappearing on pressure, not raised above the 
skin, and extending over the body and limbs. It ought to be 
added that this patient, who up to that period had been in good 
health, was seized with the disease the day after she had been 
employed in washing the clothes of the porter of the hospital, 
who had just died of fever. 

It is not my purpose to follow out in detail Dr. Shattuck's 
analysis and comparison of the phenomena presented in his cases. 
Throwing out one of the cases, he divides the remaining twelve 
into two series — the first corresponding in its general features to 
typhoid fever — and the second distinguished from the first by the 
absence of abdominal symptoms, of the lesions of the glands of 
Peyer, by presence of a peculiar eruption, and by the liability to 
the disease on the part of older persons. The first series consists 
of three cases, one of which terminated fatally ; the second consists 
of nine cases, four of which were fatal. 

These observations, although few in number, are very valuable. 
They were made under interesting circumstances, by a competent 
and accomplished observer ; and they show conclusively, so far 
as they go, that many cases at least of the continued fever of 
Britain, may readily be distinguished during life from the typhoid 
fever of France and our own country ; and that they are not cha- 
racterized by the same anatomical lesion which is present in the 
latter. 

The forty-fifth volume of the Edinburgh Medical and Surgical 



DIAGNOSIS. — HISTORICAL. 295 

Journal contains some observations on Continued Fever, as it 
occurs in the city of Glasgow hospitals, in the form of a letter to 
the editors, by Dr. Robert Perry. The only thing in these obser- 
vations which it is at all important for me to notice, is the view 
which Dr. Perry takes of the relations between dothinenteritis and 
typhus fever. He looks upon the intestinal lesion as an accidental 
complication of typhus fever, and not less frequently, also, of 
smallpox ; and says that, in the latter disease, the morbid ap- 
pearances in the intestine are the same as those which occur in 
dothinenteritis itself, which disease, he says, may also exist as an 
affection per se, characterized by its peculiar symptoms ; and 
from his enumeration of these symptoms, it is very certain that 
he has reference to typhoid fever. It is quite clear that Dr. Perry's 
observations, notwithstanding their extent, and he speaks of hav- 
ing made three hundred autopsies, have not been sufficiently 
accurate and discriminating to aid us much in the settlement of 
nice and difficult questions of diagnosis, like the one under con- 
sideration. 

In the month of April, 1840, Dr. Alexander P. Stewart read, 
before the Parisian Medical Society, a valuable paper upon the 
question of the identity or non-identity of typhoid and typhus 
fevers. This paper is contained in the Edinburgh Medical and 
Surgical Journal, for October, 1840. Dr. Stewart says that 
when he began, in 1836, the practical study of fever, he was 
much struck with the simultaneous occurrence, in the wards of 
the Glasgow Fever Hospital, of tivo sets of cases, in which the 
symptoms, however little most of them might seem to differ, when 
viewed individually , presented, when taken collectively, characters 
so marked as to defy misconception, and to enable the observer to 
form with the utmost precision the diagnosis of the nature of the 
disease, and the lesions to be revealed by dissection. In one class 
of cases, the affection, when it was mild in its character, and of 
short duration, was not attended by any eruption ; while those 
cases in which it was fatal presented an abundant and generally 
a profuse eruption ; but in the other class of cases, which equally, 
and even in a much higher proportion, went on to a fatal termi- 
nation, there was rarely any and at most only a very scanty erup- 
tion. Dr. Stewart also noticed that the disease, in the latter 
class of cases, was much more gradual in its progress and pro- 
longed in its duration than in the former ; and, finally, to com- 



296 TYPHUS FEVER. 

plete the contrast, already so striking, dissection proved the exist- 
ence in the one disease of most extensive local lesions, and in 
the other the absence of all prominent local lesions whatsoever. 
Dr. Stewart then proceeds to consider at some length the leading 
features of difference between these two diseases, in regard to 
their origin, their proximate causes, their course and duration, 
some of their symptoms, some of their anatomical lesions, and 
their treatment. He considers it settled that the poison of typhus 
is frequently generated by the crowding together of great num- 
bers of individuals in close and unventilated places, while the 
similar origin of typhoid fever is, at least, very doubtful ; that 
typhus is eminently contagious, while typhoid fever is so to a 
much more limited extent, and only under peculiar circumstances ; 
that the mean duration of typhus is much less than that of typhoid 
fever ; that relapses are as common in the latter as they are rare 
in the former ; that well-marked crises occur frequently in typhus, 
but never in typhoid fever ; that the symptoms connected with 
the abdomen and that the cutaneous eruption are very dissimilar 
in the two diseases ; that there is no resemblance between the 
anatomical lesions ; and that the treatment which may be best 
adapted to one disease may be most unsuited to the other. 

Dr. Stewart had studied typhus fever in Glasgow, and typhoid 
fever both in Glasgow and Paris, before the publication of his 
very interesting and instructive paper ; and many of his conclu- 
sions are founded upon his own careful observations of the two 
diseases. I cannot help remarking that it is somewhat singular 
that, amongst the many observers whom he quotes in support of 
the views which it is the object of his paper to establish and to 
illustrate, he should have wholly overlooked the researches of our 
countryman, Dr. Gerhard, who, by his history of the epidemic 
typhus of Philadelphia, in 1836, had done more than any other 
observer towards determining the very questions which constitute 
the subject of Dr. Stewart's essay. 

It is proper that I should notice here, very briefly, some re- 
marks upon this subject, appended to an elaborate prize essay, 
on the sources and mode of propagation of the continued fevers 
of Great Britain and Ireland, by Dr. William Davidson, of Glas- 
gow. Dr. Davidson institutes a loose general comparison of the 
symptoms of the two fevers, and pronounces them nearly or quit 
identical. He gets over the difference in regard to diarrhoea, by 



DIAGNOSIS. — HISTORICAL. 297 

attributing its frequency in the typhoid fever of Paris to the 
neglect of the French to use purgatives, and to the consequent 
irritation of the intestinal mucous surface, by the retained ft 
The seeming difference in relation to the comparative frequency of 
meteorism in the two diseases, he explains by supposing that the 
French apply this term to much slighter distensions of the abdo- 
men than would justify the English in its use. He quotes Dr. 
Lombard to show that the symptoms of the two fevers are the 
same. Dr. Lombard's opinions upon this subject may be very 
sound ; but we have already seen that his observations, so far as 
the symptoms of the diseases are concerned, were too few and 
too hurried to be of any value whatever. Dr. Davidson admits 
that the intestinal lesion is very rare on his side of the channel, 
and almost invariable on the other ; but this circumstance he 
seems to suppose may be accounted for by differences of climate, 
diet, habits, &c. So far as Dr. Gerhard's researches are con- 
cerned, in relation particularly to the lesions, he beg3 the ques- 
tion entirely, by implying that the disease which he describes 
could hardly have been British typhus, since fifty consecutive 
inspections of that disease could not be made without finding one 
decided instance of alterations in the intestinal follicles. He 
also misunderstands Dr. Gerhard, in representing him as resting 
his diagnosis of typhus almost exclusively on the absence of the 
lesion, and as admitting the almost perfect identity of the symp- 
toms of the two diseases, neither of which does Dr. Gerhard do. 
In conclusion, he admits that "the strength of his argument" in 
favor of the identity of the two fevers lies in the fact that it has 
been admitted that cases of typhoid fever have occurred with 
no intestinal lesion. After the full exposition which has been 
given of this particular point, and the extreme infrequency which 
has been shown of the occurrence itself, it is obvious enough that 
the argument deduced from it is characterized by anything rather 
than strength. 

In an inquiry into the sources and mode of action of the poison 
of fever by Dr. Alfred Hudson, physician to the Kavan Fever 
Hospital, republished in this country in connection with the 
above-mentioned Essay in Dr. Dunglison's Medical Library, the 
author takes the opposite view of this subject. He recognizes 
the essential dissimilarity of typhus and typhoid fevers ; and 
gives the valuable results of his own personal observations in the 



298 TYPHUS FEVER. 

following words : " In the Navan Fever Hospital there have been, 
for the last seven years, almost always two distinct forms of 
fever present ; one or the other occasionally preponderating, so 
as at times nearly to exclude the other. Thus, for the first three 
years, the prominent features were pain, tenderness and meteor- 
ism of the abdomen, diarrhoea, and not unfrequently these symp- 
toms combined with catarrh ; several cases of perforation of the 
ileum occurred towards the close of this period ; petechia were 
not frequent, and were late in their appearance, and we had few 
instances of communication by contagion. During the three fol- 
lowing years a highly contagious fever prevailed, and the symp- 
toms and treatment were completely different;* delirium, subsultus, 
dysphagia, being the ordinary symptoms, and diarrhoea being 
rarely met with ; nearly every case presented the measly efflores- 
cence, and instances of contagion were as numerous as they had 
been rare previously. During the present summer, the prevail- 
ing type has been the abdominal fever of the first period, and 
instances of typhus are infrequent, certainly not a fourth of the 
whole, and sent exclusively from a district in which the epidemic 
of last year still lingers. 

At a meeting of the Dublin Pathological Society, January 31, 
1846, Dr. Greene stated that, whenever he met with the phe- 
nomena so accurately described by Louis, as belonging to typhoid 
fever, he invariably concluded that follicular disease of the in- 
testine was present. 1 

Many of the French writers upon typhoid fever, of the present 
period, seem to incline to the opinion that the camp and jail 
fever of former observers, and the typhus of the British authors, 
are identical with that of their own country. In 1837, the Royal 
Academy of Medicine crowned with one of its prizes a memoir 
by M. Gaultier de Claubry, upon the differences and analogies 
between typhoid and typhus fevers, the conclusion of which 
memoir is in these words: "There are no means of distinguishing 
typhus from typhoid fever, in relation either to the lesions or 
the symptoms of the two diseases." The same writer, as late as 
October, 1839, says that the identity of the two diseases is 
henceforth put beyond doubt. It is proper to add that, at the 
same time, the Academy bestowed a second prize upon another 

1 Dublin Hospital Gazette, March, 1846. 



DIAGNOSIS. — HISTORICAL. 299 

memoir upon the same subject, in which the opposite doctrine was 
advocated. In regard to the memoir of Gaultier de Claubry, it 
is important to state that his object is to demonstrate the identity 
of the typhoid fever of Paris, and the jail, army, and camp fevers 
of the continent of Europe. He formally puts aside tin British 
typhus. He insists, as though it was one of the strongest points 
in his argument, upon the constant presence, in the continental 
jail and camp fever, of the lesion of Peyer's glands. This ques- 
tion has since been very fully discussed by the Royal Academy. 
I only wish it to be clearly understood that the question is quite 
different from the one now before us. 

In the Archives Generates de Medecine for January and Feb- 
ruary, 1842, there is an interesting history of a supposed epidemic 
typhus fever, which prevailed at Rheims, between the first of 
October 1839, and April 1840, by M. H. Landouzy; in the 
course of which the author considers, at some length, this question 
of the differences and resemblances between typhus and typhoid 
fevers. The epidemic was confined to the inmates of a certain 
quarter of the prison of Rheims, and to those whose occupations 
brought them into close connection with the patients after they 
were removed from the prison to the hospital, where they were 
all immediately and successively taken on the appearance of the 
fever. The entire number of cases was one hundred and thirty- 
eight, one hundred and three of which were amongst the inmates 
of the prison; the remaining thirty-five consisting of physicians, 
medical students, nurses, and others connected with the hospital 
where the patients were treated. 

There are some circumstances which render the history of this 
particular epidemic one of great value. I will mention only one, 
and that is, that all the cases came under the observation of the 
medical attendants immediately on the commencement of the 
disease. This is rarely the case in hospital practice ; and, in the 
present instance, it afforded a good opportunity for the study of 
the earliest phenomena of the disease. I shall give a brief 
abstract of its history. 

Amongst the first and most prominent symptoms of the epidemic 
was stupor. It frequently showed itself as early as the second or 
third day, and continued until it was lost in coma or delirium. 
ME. Landouzy does not mean by this stupor any degree of mere 
somnolence, or coma. He thinks that it differs from either of 



300 TYPHUS FEVER. 

these states. The expression of the countenance is that of half- 
^demented and stupid astonishment. This is the stupor attonitus 
of Foes. In half the cases it was strongly marked, in the other 
half it was slight in degree. M. Landouzy thinks that it comes 
on earlier and is more striking than the same symptom in typhoid 
fever. True somnolence and coma appeared in a certain number 
of cases later in the disease, often about the tenth day. Profound 
coma, so that the patient could not be roused, existed in only 
twelve cases. Delirium was very common, usually making its 
appearance between the third and the eighth day. It was gene- 
rally low and muttering in its character, and in fatal cases it 
continued until death. Headache was uniformly present at the 
commencement of the disease. It was for the most part dull 
and heavy, and felt especially over the eyes. It continued for an 
uncertain period of time, gradually disappearing or losing itself 
in coma or delirium. Subsultus tendinum was common and 
strongly marked in grave cases. Redness of the eyes, tinnitus 
aurium, and deafness were present in a certain proportion of 
cases, but differed in no obvious particulars from the same symp- 
toms in typhoid fever. There was great loss of muscular strength 
from the beginning of the disease. 

In every case except the first, which was not carefully ex- 
amined, there was an abundant cutaneous eruption, consisting of 
small spots or ecchymoses, as M. Landouzy calls them, of a red, 
violet, or black color, not elevated above the skin, and not dis- 
appearing on pressure. They were always found on the chest, 
often also on the abdomen, and in some cases they extended to 
the arms and legs. They commonly showed themselves about 
the fourth or fifth day, and gradually faded away between the 
tenth and the eighteenth. They were abundant and confluent 
in proportion to the gravity of the disease. The bodies of the 
sick exhaled a strong, offensive odor, resembling that of mice. 

In regard to the absence of appetite, to thirst, the state of the 
lips, tongue, and mouth, nothing special was observed differing 
from what occurs in typhoid fever. Nausea was present at the 
commencement of the disease in all the cases. Meteorism and 
abdominal pains were uniformly absent. There was diarrhoea at 
the beginning of the disease in only four cases. In all the others, 
there was no apparent disturbance in the functions of the intesti- 



DIAGNOSIS. — HISTORICAL. 301 

nal canal. The bowels were more inclined to constipation than 
to looseness. 

A distinct, well-marked, sibilant rhonchus was present in all 
the cases. There was nothing remarkable in the frequency of the 
pulse. It was full and large, and, at the commencement of the 
disease, resisting. There was nothing unusual in the appearance 
of the blood. Epistaxis occurred in only eight cases. The tem- 
perature of the surface was uniformly elevated; the heat was dry 
and burning. In no instance was there gangrene of any part of 
the body. 

The contagious character of the epidemic was very manifest, 
as has already been intimated. Three physicians, six medical 
students, twelve nurses, and other attendants on the sick, after 
they had been transferred from the prison to the hospital, amount- 
ing in all to thirty-five, contracted the fever. Amongst these 
there were nine deaths, or one in four, nearly ; while amongst the 
one hundred and three prisoners there were only eight deaths, or 
one in thirteen, nearly. None of the nurses who had had typhus 
fever in 1814 were attacked with the disease, but two medical 
students and one physician who had had typhoid fever, the 
former six months and the latter twenty years previously, suf- 
fered very severely. 

Of one hundred and four patients in whom the age was accu- 
rately ascertained, sixty were from fifteen to thirty years old, 
thirty-six were from thirty to fifty, and eight were from fifty to 
seventy. 

The quarter of the prison in which the disease commenced, and 
to which it was almost exclusively confined, was originally in- 
tended to accommodate from eighty to one hundred inmates ; it 
had usually contained from one hundred to one hundred and 
twenty ; at the time when the epidemic appeared, its population 
amounted to one hundred and eighty. 

Many, indeed most, of the foregoing circumstances in the his- 
tory of this local epidemic, correspond to the phenomena which 
we have found to occur in typhus fever. But, according to M. 
Landouzy, in the six autopsies which were made, the intestinal 
lesions characteristic of typhoid fever were present. The ellip- 
tical plates were either thickened and elevated, or they were the 
seats of ulcerations, and the mesenteric glands corresponding to 



302 TYPHUS FEVER. 

them were enlarged. The spleen was not increased in size in 
any of the cases ; in four it seemed somewhat softened. 

In this epidemic, if entire reliance is to be placed upon the ob- 
servation of its historian, there seems to have been a union in the 
same cases of many of the elements which are generally found 
confined either to one or the other forms of continued fever. 
The symptoms of contagious typhus were found in connection 
with the follicular lesion of typhoid fever. Is it possible that, 
even admitting the two diseases to be essentially dissimilar, under 
certain circumstances the causes of both may be so commingled, 
as to give rise to a mixed disease in which there is a combination 
of the elements of both ? Let it be remembered that this, as well 
as all analogous questions, is to be determined, not by a priori 
reasoning, however plausible and ingenious, but by simple, care- 
ful, rigorous observation. M. Landouzy, in the case before us, in 
the spirit of a true and sound philosophy, says, that we must await 
the results of ulterior observation before we shall be able to settle, 
definitively, this great question in regard to the identity of these 
several forms of fever. "In effect," he adds, "if in all future 
epidemics of the typhus of camps, of jails, of hospitals, &c, we 
find, as in that of Rheims, complete absence of disease of the 
spleen, and great differences between the symptoms and those of 
typhoid fever, we must confine ourselves to the conclusion that 
typhus and typhoid fever are analogous and not identical dis- 
eases. If, on the contrary, we find that in one epidemic diar- 
rhoea is absent, in another the petechial eruption, in another the 
rose spots, and so on, we must conclude that these differences 
depend only upon variations in the action of the epidemic cause, 
and that the disease is, in its nature and essence, identical with 
typhoid fever." M. Landouzy 's conclusion, in regard to the 
epidemic which constitutes the subject of his memoir, is, that the 
resemblances between it and typhoid fever are so numerous as to 
induce him to look upon the two diseases as analogous ; but that 
the differences between them are also too numerous to allow him 
to regard them as identical. 

I shall conclude this historical survey of facts and opinions, 
bearing upon the question of diagnosis before us, by a short re- 
ference to an article contained in the July and October numbers 
of the British and Foreign Medical Review for 1841. This arti- 
cle contains a pretty full exposition of the subject under considera- 



DIAGNOSIS. — HISTORICAL. 303 

tion, and abating some mere smartnesses in its criticisms of Chris- 
tison, Gerhard, Lombard, and Staberoh, it is written in a good 
spirit, as well as with fairness and ability. Its noble tribute to 
Louis has already been noticed. The writer of the paper, after 
an examination of all the accessible and valid evidence in the 
case, comes to the conclusion that the contagious typhus of Great 
Britain and the typhoid fever of France are different varieties, 
only, and not distinct species of disease. I have already gone 
over nearly all the ground occupied by this writer ; I shall have 
occasion, therefore, to notice only two or three of his statements 
and opinions. The most important of these, in its connection with 
the diagnosis of the two diseases, is this : in his tabular compari- 
son of typhoid fever and typhus, he sets down, so far as the ab- 
dominal lesion is concerned, as typhus^ all the cases of fever oc- 
curring in Britain ; thus settling beforehand the very question at 
issue, in relation, at least, to one of its elements. The writer ad- 
mits that the two forms of fever may generally be distinguished 
during life, but alleges that there are cases in which such dis- 
tinction cannot be established. The number and authenticity of 
these latter, are, certainly, thus far, very limited ; and if a difference 
of symptomatology, sufficiently marked to be generally and readily 
recognized, corresponding constantly with a most important differ- 
ence in the state of certain organs, found in fatal cases, is not ade- 
quate to constitute separate diseases, it is not easy to, see in what 
radical nosological distinctions are to be found. In order to ac- 
count for the great differences in the appearances of the eruptions 
in the two diseases, the reviewer suggests the hypothesis, certainly 
improbable and gratuitous enough, that the lesions of the skin and 
of the intestine may be supplementary of each other ; a most facile 
method, assuredly, of disposing of a difficulty. 

Such is the history, as full and fair as I have been able to make 
it, of the recent investigations in regard to the relations between 
typhoid and typhus fevers. Excepting those of M. Landouzy, 
it seems to me that they all go to show that the two diseases are 
radically and essentially dissimilar. I have no wish, whatever, 
to make out a case in this matter. I would avoid, scrupulously, 
anything like special pleading. The truth, as Louis's motto from 
Rousseau says, is in the things, in the facts and their relations, 
not in my mind, which attempts to judge and to interpret them. 
I am anxious only that this truth, be it what it may, should be 



304 TYPHUS FEVER. 

ascertained. That this has been done, absolutely and definitively, 
I do not pretend. That typhoid and typhus fevers are, clearly 
and unequivocally, fundamentally distinct diseases, may not have 
been positively demonstrated. I admit, that the paper of M. 
Landouzy throws some doubt upon the question. But, as has 
been remarked before, whether the two diseases be or be not speci- 
fically and nosologically unlike each other, it is equally important 
that the wide differences which confessedly do exist between them 
should be pointed out, and their real relations established. This 
I have endeavored, so far as the present state of our knowledge 
could enable me, faithfully and truly to do. 

In regard to the identity of the former camp and jail fevers of 
the European continent, either with typhoid fever or with typhus, 
it is not possible to come to a positive conclusion. Louis, thinks 
that they were typhoid, others think that they were typhus. It 
is probable, as I have already said, that both forms of fever may 
have prevailed. At any rate, the descriptions given of them are 
generally so imperfect, that it is wholly impossible now to decide 
this question with any degree of certainty. It is quite as well, 
perhaps, not to attempt its solution at all. 

A friendly critic, in an American medical journal, expresses 
some surprise at the opinions contained in the above paragraph. 
He thinks there can be no doubt that the continental, camp and 
jail fevers were true typhus, differing essentially from typhoid 
fever. Since the publication of my first edition, I have read 
carefully the prize memoir of Gaultier de Claubry, upon this 
question, and I heard a part of the very full and animated dis- 
cussions, of which it has recently been the subject in the Royal 
Academy of Medicine, at Paris. These investigations have fully 
confirmed me in the soundness of the foregoing conclusions. It is 
impossible to read the detailed and elaborate work of M. Gaultier 
de Claubry, without being convinced that many of the epidemics 
prevailing in the armies and prisons throughout various portions 
of the Continent, from 1804 to 1814, corresponded in all respects 
to typhoid fever, while in other instances the disease was true Irish 
typhus. 

In my Essay on the Philosophy of Medical Science, I have 
endeavored to ascertain and to point out the true principles of 
nosological diagnosis ; I have attempted to lay down the rules by 
which we ought to be governed in deciding upon the individuality 



DIAGNOSIS. — HISTORICAL. 305 

of any given disease. I do not propose, here, to enter- again 
upon the discussion of this subject; I wish merely to say that the 
elements which typhoid and typhus fever possess in common 
are neither more numerous nor more striking than those which 
are possessed in common by many other diseases admitted to be 
essentially dissimilar from each other. Would not smallpox be 
constantly confounded with typhus, if neither of these diseases 
was marked by any distinctive cutaneous eruption ? In a note to 
the chapter in my essay, just referred to, I have said: "Let 
me here add that this question of the essential likeness or unlike- 
ness of these two diseases — typhus and typhoid fever — one of the 
most important and interesting questions of specific diagnosis 
that has ever occupied the attention of physicians — if submitted 
to the test of the principles which I have laid down, and fairly 
tried by them — cannot fail, I think, to be settled in favor of the 
doctrine of their fundamental dissimilarity. The two diseases 
will be found to approach each other very closely in the posses- 
sion of those morbid processes and phenomena — I mean, general 
fever of the typhoidal type, certain changes in the composition 
and quality of the blood, and certain nervous symptoms — which 
are common to many diseases, and, for this reawn, of but small 
value as diagnostic or distinctive character*: while they are 
separated clearly and broadly from each other, by the presence 
in one, and the absence from the other, of very strongly marked 
and constant anatomical lesions, and of groups of symptoms 
equally striking, constant, and characteristic. Any principles 
of diagnosis, or any rules of reasoning, that make true typhus 
fever and typhoid fever essentially one specific disease, will make 
smallpox, and oriental plague, also, nothing but varieties or 
modifications of the same single disease. This result will be 
found to be absolutely unavoidable." 1 

It is now five years since the publication of the first edition 
of my work on fever. This question of the true relationship 
between typhus and typhoid fever still remains a matter of con- 
troversy. It has been extensively discussed, both in England 
and France, and the opinion of the profession is still divided. I 
have watched this discussion closely and dispassionately, and I 
have seen nothing to induce me in any degree to modify the 

1 Essay, eta, pp. 140-141. 
20 



306 TYPHUS FEVER. 

judgment which I had formed and expressed; unless, indeed, it be 
in withdrawing altogether the slight doubt or qualification with 
which it was accompanied. The more I have studied the subject, 
and the more I have reflected upon it, the more thoroughly have 
I been convinced that the objections to the opposite doctrine are 
conclusive and insuperable, and I cannot doubt that such will be 
the final verdict of science in the issue before us. 

In connection with this subject, I have the pleasure of publish- 
ing the following interesting letter from Dr. William Power, of 
Baltimore, dated September 4, 1847. " The questions you ask 
have interested me very deeply; and this summer for the first 
time I have had ample opportunity to fix definitely my own 
opinions. What I write ybu now resumes the opinions also of 
Drs. Chew and T. Buckler, who saw the disease throughout 
its whole visitation in this city ; nor do I know of one gentleman 
who had any opportunity of studying it here who differs from us. 

"We have had for the last fourteen months an epidemic of ty- 
phoid fever in Baltimore. The wards of the almshouse and in- 
firmary have constantly contained a large number of cases of this 
disease, presenting nothing remarkable, save that the cases had, 
as a general rule, more of the adynamic type than in former 
years, and required and bore more stimulation. Early in May, 
two vessels arrived, bringing Irish emigrants ; one from Liver- 
pool, the other from the South of Ireland. Other vessels suc- 
ceeded these ; so that upwards of two hundred cases were treated 
at the infirmary, and upwards of eighty at the almshouse. These 
cases were typhus, so exactly corresponding with Gerhard's de- 
scription of the Philadelphia epidemic of 1836, that I am con- 
strained to say, I know of no better portraiture of any disease 
than that which he has given us of typhus fever. I made or 
assisted at twenty-six post-mortem examinations ; in not one did 
I see any trace of the peculiar lesion. In nine of those who 
died, having loose bowels during life, we found either the lesions of 
dysentery or of diffused muco-enteritis ; no mesenteric alteration 
in any case. The parenchymatous organs and mesenteric vessels 
were congested with a dark fluid blood; and the condition of the 
spleen, bronchial mucous membrane, lungs, and brain resembled 
what we find in congestive remittent or typhoid cases. The 
stomach was uniformly more altered, and presented deeper traces 
of inflammation than in typhoid fever. We had fourteen autop- 



DIAGNOSIS. — HISTORICAL. 307 

sies of typhoid fever during the same period, and it thrice 
occurred that we had the bodies opened side by side for the sake 
of comparison made at the time. 

" The mode of access, facies, march, eruption, symptoms, treat- 
ment, and convalescence are all different between the two dis- 
eases. We had both forms of fever at once under observation ; 
German emigrants and domestic patients with typhoid, and 
Irish and English with typhus. Nay, more than this, four of the 
seamen of the Rio Grande, a vessel which brought seventy cases 
of typhus, had true typhoid fever, and several of the steerage pas- 
sengers had the same disease. There was no mistake in the 
diagnosis in any case where the issue was fatal, as proved by the 
autopsy: and in the successful cases, the difference of eruption, 
diarrhoea, meteorism ; the peculiar nervous symptoms ; the greater 
emaciation ; bed sores, which were so rare in the worst cases of 
typhus, that I saw but two, made the diagnosis simple to every 
clever student. The effect of a full stimulant treatment made the 
difference still more obvious. In short, we have here in Baltimore, 
no doubt but the fullest conviction of the non-identity of the two 
diseases. 

"Furthermore, there is the undoubted contagiousness of typhus. 
Two of the Sisters of Charity at the infirmary — one of whom died 
— and three out of five resident students took the disease. Four 
of the hospital assistants, and several of the inmates of the alms- 
house were attacked ; many cases occurred also in the city, where 
direct intercourse could always be traced and proved. 

" Here is another interesting order of facts. A German had 
typhoid fever, and was eighty da}^s in bed under Dr. Buckler; he 
recovered, and was acting as hospital assistant; in tending the 
sick emigrants, he was seized with typhus. Two years ago, Dr. 
Berryman had at the almshouse a severe attack of typhoid fever. 
He was appointed resident physician at the new quarantine hos- 
pital, where all these cases are now sent. He took the fever and 
died last week ; — the most promising young man I have ever 
known, and whose loss has filled us all with grief. Again, one of 
the emigrants who came near dying in May last, with typhus, is 
at this very moment at the point of death, with typhoid fever. 

" There is as much difference in my mind between the two dis- 
eases, as there is between measles and scarlatina. Huxham has 
beautifully drawn the distinction between the slow nervous and 



308 



TYPHUS FEVER, 



malignant fevers ; excepting the new lights we have in pathology, 
we can add but little to what he has said. Corrigan, in Dublin, 
sees the difference between what he calls enteric and typhus 
fevers. Dr. Wood, in his late work, appears to me to have 
handled this subject better than any other of our systematic 
writers. I perfectly agree with him in his conclusions. It ap- 
pears to me that we are better placed than either the French or 
English to study this question without prejudice, and more likely 
to arrive at the truth." 

I have placed in the following tabular summary, as a matter 
of convenient reference, the leading points of distinction between 
typhus and typhoid fever, side by side. 



Typhoid Fever. 

1. Mode of Access. — More generally 
gradual, insidious, and creeping, than 
in typhus. 

2. Heat of Skin. 



3. Mind. — Delirium and other cere- 
bral symptoms coming on, and increas- 
ing gradually, after the first week, more 
generally than in typhus. 

4. Bowels. — Diarrhoea, with thin li- 
quid discharges, very common. Gurg- 
ling on pressure over region of ccecum. 
Meteorie distension or rigidity of abdo- 
men. Griping pains common. 

5. Emaciation. — More common and 
greater than in typhus. 

6. Epistaxis. — More common than in 
typhus. 

7. Hemorrhage from the Bowels. — 
Quite common. 

8. Cutaneous Eruptions. — Bright, 
scanty, rose-colored eruption; slightly 
elevated above surrounding skin; rea- 
dily disappearing on pressure ; mostly 
confined to skin of chest and abdomen. 

9. Eschars. — More common than in 
typhus. 

10. Lesions. — Peyer's glands always 
altered; generally ulcerated. Mesente- 
ric glands reddened, enlarged, and soft- 



Typhus Fever. 

1. More frequently sudden and for- 
mal than in typhoid fever. 

2. More frequently burning and pun- 
gent, during the early stages, than in 
typhoid fever. Fuliginous flush of face 
more common than in typhoid fever. 

3. Cerebral symptoms, especially 
dulness and stupor, more strongly 
marked at the onset of the disease than 
in typhoid fever. 

4. Spontaneous diarrhoea rare. Dis- 
charges from bowels not liquid. No 
gurgling on pressure over region of 
coecum. Meteoric distension very rare. 
Griping pains rare. 

5. 



6. 



7. Very rare. Does it ever occur ? 

8. In many cases, especially grave 
ones, more abundant petechial eruption ; 
not disappearing on pressure ; — in other 
cases, no eruption. 



10. Peyer's glands, and mesenteric 
glands healthy. Blood more generally 
dark and grumous. Dark engorgement 



DIAGNOSIS. — HISTORICAL. 30^ 

Typhoid Fever. Typhus Fever. 

cned. Spleen more frequently enlarged of vessels and sinuses of brain more con- 

and softened than in typhus. Ulcera- stant than in typhoid fever. 

tion of the pharynx and oesophagus 

more common than in typhus. Large 

intestines more frequently distended 

With gas than in typhus. 

11. Causes. — Confined to no geograph- 11. Limited to certain geographic.! 
ical localities. Prevailing constantly localities. Generally confined to crowd- 
and extensively amongst scattered, ed, filthy, and poorly ventilated habita- 
cleanly, well fed, and well sheltered tions. Under such circumstances emi- 
rural populations. Occasionally and nently contagious. Occurring much 
moderately contagious. More frequent- more frequently after the thirty-fiftl. 
ly sporadic than typhus. More gene- year of life than typhoid fever. 

rally limited to the early and middle 
period of life than typhus. 

12. Duration. — Average duration 12. Terminating fatally, or in recov- 
somewhat greater than typhus. Pro- ery within the first ten days much more 
longed to the fortieth or fiftieth day frequently than typhoid fever. 

much more frequently. 

13. Effects of Remedies. — Bearing de- 13. Requiring more active stimula- 
pletion better than typhus. tion than typhoid lever. 

Another period of between four and five years has elapsed 
since the publication, in my second edition, of the foregoing 
summary. I have preferred to let it stand as it was then writ- 
ten, making such additions to it here as the materials accumu- 
lated during this period have furnished. 

I do not know that this question of the true relation between 
the two great forms of continued fever is any nearer to a posi- 
tive and final solution than it was five years ago. Medical 
opinion is still divided, and somewhat singularly so, in regard to 
it. In the city of New York, where both forms of the disease — 
but more especially the typhus — have been extensively and care- 
fully studied for several years by sound pathologists, and accom- 
plished and thoroughly reliable observers, the opinion is nearly, 
if not quite unanimous, that they are forms or varieties merely 
of a single disease. This is the opinion of my colleagues, Dr. 
Smith and Dr. Clark. I regret that the observations upon 
which this opinion rests have not been recorded in such form 
and manner as to render them any further available in the set- 
tlement of this question. 

In Boston, Philadelphia, and Baltimore, the general opinion 
of the profession is the other way. 



310 TYPHUS FEVER. 

As to the state of medical opinion in Great Britain, I hardly 
feel myself authorized to speak ; I do not know that it is widely 
different from what it was five years ago. Still, it is clear 
enough, I think, that this opinion is undergoing a change; at 
least, it is true, I suppose, that recent investigations have created 
doubts as to the soundness of the commonly received doctrine 
which had not existed before. The question of the identity or 
the non-identity of typhoid and typhus fever is more generally 
regarded than it was, as still an open question — to be settled 
only by extensive, various, careful, accurate observation. 

I shall close this discussion with the words of an English 
physician, Dr. Jenner. This question has never been so care- 
fully, laboriously, minutely, and philosophically investigated be- 
fore as it has been by Dr. Jenner. My opinion of the value of 
these investigations has already been sufficiently attested ; I only 
wish to add, that apart from this value consisting in their re- 
sults, and the new light they have shed upon an obscure and 
difficult subject; they constitute one of the finest examples in 
medical history of a true and sound philosophy, and show their 
author to be a worthy inheritor of the illustrious name he bears. 

It will be borne in mind that the following summary and ana- 
lysis apply to forty-three fatal cases of typhus, and twenty-three 
fatal cases of typhoid fever. 

"1. Age. — Typhoid fever was limited, in the cases here con- 
sidered, to persons under forty years of age ; nearly one-third 
of the forty-three cases of typhus were more than fifty years of 
age. 

2. Mode of Attach. — As a general rule, the attack of ty- 
phoid fever commenced more insidiously than that of typhus 
fever. This observation, like all others in this paper, applies, of 
course, only to fatal cases. 

3. Duration. — The average duration of the fatal cases of 
typhoid fever was twenty-two days. Of the fatal cases of typhus 
fever fourteen days. Half the cases of typhoid fever survived 
the twentieth day of disease. Not a single case of typhus fever 
survived the twentieth day of disease. 

4. Eruption. — The difference in the appearance of the erup- 
tion in the two diseases was as great as it well could be, con- 
sidering that both were of a reddish hue. 

5. 3Iiliary Vesicles, or Sudamina. — These vesicles were 



DIAGNOSIS. — HISTORICAL. 311 

present in an equal proportion of the cases of both diseases under 
forty years of age. But in no case of typhus fever, more than 
forty years of age, were they detected. 

Subsequent experience leads me to believe that miliary ve- 
sicles are rarely seen on individuals more than forty years of 
age ; and very rarely, indeed, if ever, on patients more than fifty 
years old. I have during the last year, i. e., since my attention 
was directed to this point, seen these bodies on no one of the 
many patients more than fifty years of age laboring under various 
diseases that have come under my observation. 

6. Expression, Manner, Hue of Face, §c. — As the rule in 
the cases of typhoid fever here analyzed, the expression was 
much less indicative of prostration, and more anxious than in 
the cases of typhus fever. In the former disease the complexion 
was tolerably clear, and the flush, when present, was of brightish 
pink color, limited to one or both cheeks, and often distinctly 
circumscribed. In typhus fever, on the contrary, the complexion 
was thick and muddy, the flush of the face uniform and of a 
dusky red color. 

7. Headache was a constant symptom in all the cases of typhoid 
and typhus fever ; but it disappeared by about the tenth or 
twelfth day in the latter, and not till the termination of the 
second or middle of the third week in the former. 

8. Delirium commenced in three only of ten cases of typhoid 
fever before the fourteenth day ; while it begun in fourteen out 
of fifteen cases of typhus fever before the fourteenth day. As 
a rule, the delirium was decidedly more active in typhoid than 
in typhus fever. 

9. Somnolence. — In eight out of nine cases of typhoid fever, 
somnolence commenced after the fourteenth day of disease. In 
seventeen out of eighteen cases of typhus, before the termination 
of the second week. 

10. Coma-vigil. — One-fifth of the cases of typhus fever ex- 
perienced coma-vigil ; not a single case of typhoid fever experi- 
enced that condition. 

Spasmodic movements were nearly equally frequent in the 
two diseases. 

11. Retention of urine, and involuntary discharge of urine 
and stools, occurred with equal frequency in the two diseases, 
but at a much earlier date in typhus than in typhoid fever. 



312 TYPHUS FEVER. 

12. Loss of Muscular Power. — Little more than a fourth 
of the patients attacked with typhoid fever kept their bed entirely 
before the 7th day of disease. All the patients affected with 
typhus, whose cases are here considered, took altogether to their 
beds before the 7th day of disease. The prostration was rarely 
so extreme in the cases of typhoid fever as in those of typhus. 
Extreme prostration, when it did occur in typhoid fever, was not 
observed till from the 14th to the 30th day, while in a large 
majority of the cases of typhus fever it was marked between the 
9th and 12th days of disease. 

13. Epistaxis was present in five of fifteen cases of typhoid 
fever — in not one of twenty-three cases of typhus fever. Sear- 
ing was equally and similarly affected in the two diseases. 

14. Eyes. — The conjunctivae were very much more constantly 
and intensely injected in the cases of typhus than in those of 
typhoid fever ; the pupils were absolutely larger than natural in 
a majority of the cases of the latter disease, while they were 
abnormally contracted in a large majority of the cases of the 
former affection. 

15. Tongue. — Although individual cases of the two diseases 
may have closely resembled each other in the appearance of the 
tongue, yet, taking the whole of either group of cases, this organ 
presented a singularly different aspect in the one from what it 
did in the other. It was much more frequently moist throughout 
the disease in typhoid than in typhus fever. When dry it was 
often red, glazed, and fissured, in the former ; rarely so in the 
latter. Again, in typhoid fever, when the tongue was brown, its 
hue was much less deep — it was of a yellowish, instead of a 
blackish, brown. The small dry tongue, with red tip and edges, 
smooth, pale brownish-yellow fur, fissured — the surface seen 
between the fissures being deep red — may be considered differ- 
entially as a diagnostic sign of typhoid fever. One only of 
twenty patients affected with typhoid fever, but eight of forty 
patients laboring under typhus fever, were unable to protrude 
the tongue when bidden. 1 

16. Intestinal hemorrhage occurred in one-third of the pa- 
tients affected with typhoid fever — in none of those suffering 

1 This clearly indicates the difference in the amount of prostration in the two 
diseases. 



DIAGNOSIS. — HISTORICAL. 313 

• 
from typhus fever. The other abdominal symptoms and signs 
need no recapitulation. 

17. Pulse. — The frequency of the pulse fluctuated much 
more, from day to day, in the cases of typhoid than in those of 
typhus fever. 

18. Cough and Physical Chest Signs. — Sonorous rale was 
very much more frequently present in the cases of typhoid than 
in those of typhus fever — i. e., it was present in eleven out of 
twelve cases of the former, and in seven only of twenty-one cases 
of the latter. Dulness of the most depending part of the chest, 
from intense congestion of the lung, was observed in nine cases 
of typhus fever — in no case of typhoid fever. 

19. Erysipelas occurred in seven of the twenty-three — i. e., 
in nearly a third of the cases of typhoid ; in two only of the 
forty- three cases of typhus fever — t. e., in less than one-twen- 
tieth of them. 

20. Cadaveric rigidity ceased much more quickly in the sub- 
jects dead from typhus fever than from typhoid fever. 

21. Discoloration of the walls of the abdomen, and of the 
skin covering the larger veins, was much more frequently present 
in those dead from typhus than typhoid fever. 

22. Emaciation had made greater progress in the typhoid 
than in the typhus subjects. 

23. Spots. — The spots observed during the progress of the 
cases of typhus fever continued after death ; no trace of the 
spots visible during life could be detected after death from typhoid 
fever. 

24. Head. — After typhoid fever, the pia mater and arachnoid 
separated from the convolutions with abnormal facility in one 
only of nine cases examined with reference to this point. The 
vessels of the pia mater were abnormally filled with blood in one- 
third of the cases, but intensely congested in one of fifteen cases ; 
the cerebral substance was congested in one seventh of the cases. 
After typhus fever, the pia mater and arachnoid separated with 
abnormal facility in nine of eleven cases, of which notes on the 
point were made. The vessels of the pia mater were congested 
in nearly half, and intensely congested in one-fifth of the whole 
of the cases ; while the cerebral substance itself was abnormally 
congested in half. 

Hemorrhage into the cavity of the arachnoid, which was 



314 TYPHUS FEVEK. 

not found in a single case of typhoid fever, had occurred before 
death in one-eighth of the cases of typhus fever. The amount 
of serosity found within the cranial cavity was decidedly greater 
after typhus than typhoid fever. 

25. Pharynx. — After typhoid fever, this organ was found 
ulcerated in one-third of the cases. After typhus fever, ulcera- 
tion of the pharynx was not detected in a single case. 

26. Larynx. — Ulceration of the larynx was found in one of 
fifteen subjects, dead from typhoid fever ; in one of twenty-six 
from typhus fever. 

27. (Esophagus. — After typhoid fever, ulcerated in one of 
fifteen cases in which it was examined. After typhus fever, the 
oesophagus was free from ulceration in all the twenty-four cases 
in which it was examined. The epithelium separated from the 
oesophagus spontaneously at an earlier period after death from 
the latter than the former disease. 

28. Stomach. — In none of the fifteen cases examined after death 
from typhoid fever, was the mucous membrane of the stomach 
softened throughout its whole extent ; in no case did softening of 
the cardiac extremity approach perforation. In four of thirty- 
seven cases of typhus fever, the whole mucous membrane of the 
stomach was softened ; and in four others there was such extreme 
softening of the whole of the coats of the great cul-de-sac, that 
they were perforated by the slightest violence. 

29. Small Intestine and Mesenteric Glands. — The presence 
or absence of lesion of these organs, was the ground on which the 
cases of typhoid and typhus fever here analyzed were divided 
from each other ; consequently they were invariably diseased in 
the one and normal in the other. 

30. Large Intestines. — After death from typhoid fever, the 
mucous membrane of the large intestines was found ulcerated in 
rather more than a third of twenty cases. In no instance after 
death from typhus fever. 

Peritoneum. — As peritonitis was in typhoid fever secondary 
to, and dependent on the entero-mesenteric disease, it may here 
be excluded from consideration. 

31. Spleen. — This organ was enlarged in all the cases of 
typhoid fever ; softened in one-third of the cases only. Before 
the age of fifty, it was as large after typhus as typhoid fever ; 
after that age, it was decidedly smaller in the former than in the 



DIAGNOSIS. — HISTORICAL. ' 315 

latter affection. After the age of fifty, it was as soft in typhus 
as in typhoid fever ; before that age, it was less frequently soft- 
ened. 

32. G all-Bladder : — There was ulceration of the lining mem- 
brane of the gall-bladder in one of fourteen cases of typhoid 
fever ; in none of thirty-one cases of typhus fever. In the latter 
disease the bile was much thicker, and of a darker green color, 
than in the former. 1 

33. Liver, Pancreas, Kidneys. — These organs were more flabby 
in the cases of typhus than in those of typhoid fever. 

Urinary Bladder. — This viscus was ulcerated in one of the 
cases of typhoid fever — in none of the cases of typhus fever. 

34. Pericardium. — This cavity contained a small amount of 
yellowish transparent serosity, in all the cases of typhoid fever 
examined. The contained serosity was red, from transudation of 
a solution of haematosin, in five of thirty-one cases of typhus 
fever. 

35. Heart. — The muscular tissue of this organ was much more 
frequently and decidedly flabby, and its lining membrane was 
much more frequently and deeply stained of a dark red color, 
in the cases of typhus fever than in those of typhoid fever. 

36. Lungs. — Granular and non-granular lobular consolidation 
were very frequent in the subjects dead from typhoid fever — rare 
in those dead from typhus fever. The reverse was the fact with 
reference to consolidation from congestion of the most depending 
part of the lungs. 

37. Pleura. — Recent lymph or turbid serosity was found in 
six of fifteen cases of typhoid fever — i. e., between half and one 
third, or in the proportion of forty per cent. The same lesions, 
but much less in amount, were found in two only of thirty-six 
cases of typhus fever — i. <?., one-sixteenth, or in the proportion 
of 5.5 per cent. 

The particulars here briefly recapitulated, and still more those 
fully detailed in the foregoing papers, appear to me to prove 
indisputably that the symptoms, causes, duration, anatomico- 
pathological lesions, and the tendency to cadaveric changes, are 
different in typhoid fever to what they are in typhus fever. 

To account for the differences in symptoms which exist in con- 

1 The condition of the bile, as found after death in these two diseases, is 
worthy of more careful investigation. The difference in appearance is, in a large 
majority of cases, well marked. 



316 • TYPHUS FEVER. 

tinued fever, with and without entero-mesenteric disease, the two 
following assertions have been put forward: 1. That typhoid 
fever is merely typhus fever complicated with lesion of a par- 
ticular organ; and therefore it is to be expected that certain 
symptoms referable to, and dependent on, that lesion will be 
present, and so far modify the symptoms of the disease. 

If the symptoms and signs referable to the intestinal disease 
as a cause— -i. e., the condition of the tongue, the diarrhoea, in- 
creased resonance, and fulness of the abdomen, gurgling in the 
iliac fossa, pain and tenderness in the same region, or even the 
daily fluctuations in frequency of the pulse — were the only symp- 
toms by which typhoid fever was separated from typhus fever, 
although the idea might cross the mind that they were two dis- 
eases, no sufficient ground for their separation would be present, 
unless the specific cause of the one was proved to be different 
from that of the other. But putting aside the symptoms strictly 
referable to the abdominal lesion, the general symptoms of the 
two diseases, in the cases here analyzed, differed widely ; such 
differences having no apparent connection with the local affection, 
but being probably like it, dependent on some common cause 
acting on the whole system simultaneously. Thus the remark- 
able differences in the kind, not simple amount, of the rash in 
the two diseases, and the tendency to local inflammation, to 
erysipelas, and to ulceration, observed in the cases of typhoid 
fever here analyzed, cannot, with any show of reason, be con- 
sidered to have been dependent on the diseases of Peyer's patches 
— i. <?., in the same way as the abdominal signs undoubtedly were ; 
and it is to be carefully borne in mind that the external, the 
hygienic conditions of either group of cases, were precisely the 
same in all respects. They occupied the same wards, partook of 
the same diet, slept on the same beds, under the same amount of 
clothing, and had the same physician to attend them, and the 
same nurses to wait on them. 

Moreover, of the symptoms common to the two, the headache 
continued longer, and the delirium and somnolence came on, as 
we have seen, much later, in typhoid than in typhus fever ; and 
the delirium, too, possessed a more active character. These 
differences, also, cannot be explained by the presence of intes- 
tinal disease in the former, and its absence in the latter affection. 

The short comparative duration of the cases of typhus fever, 



DIAGNOSIS. — HISTORICAL. 317 

here considered, is another remarkable point of difference, totally 
inexplicable by the hypothesis, that typhoid fever is typhus fever 
with intestinal ulceration. Had the cases eventually recovered, 
it might have been said, that the intestinal lesion prolonged the 
disease in the cases of typhoid fever ; but that all the fatal cases 
of fever, with a local lesion of so severe a nature as that recorded 
to have been present in the cases of typhoid fever, should have 
had a much longer course than all those other fatal cases of fever 
in which no organic change of structure could be detected after 
death, appears to me inexplicable, on the supposition that the 
former is simply the latter disease, with this serious lesion super- 
added. Let me repeat, by this hypothesis we are asked to imagine 
that death is retarded in fever by extensive ulceration of the 
small intestines, and enlargement, softening, and even suppura- 
tion of the mesenteric glands. Surely it behoves the supporters 
of such a statement to bring forward cogent proofs of the identity 
of the specific cause of the two affections ere they ask us to admit 
its truth. 

The same mode of reasoning appears to me equally conclusive, 
when we consider the comparatively early period of the disease 
at which the patients, suffering from typhus fever, lost the ability 
to make muscular exertion. For, to suppose that the presence 
of abdominal complication in fever invariably prevented the 
extremely early supervention of debility, is, a priori, still more 
absurd than to suppose such lesions to have retarded death. 
How, again, are we to explain, if we regard typhoid as typhus 
with abdominal complication, the differences observed in the ages 
of the patients, in their general manner ; the muddy hue of the 
skin, and uniform flush of the face, the injected conjunctivae and 
contracted pupils in typhus fever ; and the comparatively clear 
complexion, the pink flush limited to the cheeks, the pale con- 
junctivae and the large pupils, in typhoid fever ? 

In what way, also, are we to account for the differences 
observed in the physical breath-signs, on the supposition that 
the one is merely the other, with abdominal complication ? Death 
itself, moreover, adds new proof to the non-identity of the gene- 
ral affection in the two diseases. The comparatively rapid loss 
of muscular rigidity, the discoloration of the surface, the more 
flabby condition of the heart, liver, and kidneys, the extreme 
softening of the stomach, and the early separation of the epithe- 



318 TYPHUS FEVER. 

Hum, after typhus fever, are all cadaveric changes, by which 
death makes us cognizant of a condition of the system at large, 
which condition must have existed anterior to the cessation of 
life from that disease ; and which condition could not have been 
present in the cases of typhoid fever, or death would have made 
it manifest. 

I need not here more than advert to the differences observed 
in the lesions which death simply enabled us to lay bare. The 
almost constantly congested brain and membranes in typhus 
fever ; the frequent presence of the signs of pre-existing serous 
inflammation in typhoid fever ; the difference in the nature of 
the pulmonary lesions in the two — are inexplicable on the sup- 
position that the one disease is the same as the other, excepting 
so far as concerns the abdominal affection. Thus tried by facts 
— i. e., by recorded symptoms and lesions — the assertion that 
typhoid fever is merely typhus fever with abdominal complica- 
tion, is completely refuted. 

2. But another mode of explaining the differences which 
exist between the two diseases has been given — i. e., that the 
differences observed depend on variations in the epidemic consti- 
tution. These cases afford a complete answer to this assertion. 
For the majority of the cases here analyzed of both diseases were 
observed during the same epidemic constitution. I may remark, 
that during three years' attentive watching of nearly all the 
cases admitted into the London Fever Hospital, in which time 
there have been epidemics of relapsing fever, typhus fever, and 
cholera — and consequently, according to those whose opinions I 
am here examining, as many changes in epidemic constitution — 
I have seen no alteration in the general or particular symptoms 
of either typhus or typhoid fevers, or the lesions observed after 
death from either — i. e., from November, 1846, to November, 
1849. The cases of typhoid fever — which disease is rarely 
absent for a fortnight from the wards of the hospital — preserved 
their symptoms unchanged, and presented the same lesions, 
whatever the epidemic constitution that prevailed ; the same is 
true of typhus fever. Cases of the latter disease are also rarely 
absent from the wards of the same institution. It is there com- 
mon to see patients occupying beds side by side, and presenting 
respectively the well-marked characters of either disease. But 
to return to the particular cases here analyzed. Allowing to 



DIAGNOSIS. — HISTORICAL. 319 

epidemic constitution all the power of modifying disease claimed 
for it by certain writers, it must be granted that, whatever influ- 
ence this epidemic constitution exercised over the group of cases 
without intestinal lesion, it ought to have exercised over the 
group of cases with intestinal lesion, because the cases of the 
two groups were scattered indiscriminately over the space of two 
years only. If, I repeat, the two affections were really the same 
disease, then the same epidemic constitution ought to have im- 
pressed on both the same general features, implanted in both the 
same local lesions, and given to both the same tendency to 
cadaveric change, and this, allowing for all the modifying influ- 
ence which the accidental presence of the abdominal lesion in the 
one and its absence from the other group might have occasioned. 
The analysis of every symptom and every lesion shows that the 
two affections were not thus assimilated by the prevalence of any 
particular epidemic constitution. But if this epidemic constitu- 
tion, by any stretch of the imagination, could be supposed to 
change from week to week, to cause the case attacked to-day to 
have typhus fever, the individual who takes the disease to-morrow 
to have typhoid fever, still, it could not account for the fact — as 
well established as any fact in medicine — that typhoid fever 
rarely, if ever, affects persons more than fifty years of age ; 
while age exerts little influence in determining the occurrence of 
typhus fever. 

Thus, then, the assertion that typhoid fever is merely typhus 
fever modified by the prevailing epidemic constitution, is as irre- 
concilable with facts, as that the former disease is simply the 
latter with abdominal complication. 

To conclude. At the commencement of this analysis, I pro- 
posed to examine whether typhoid fever and typhus fever differed 
from each other in the same way as smallpox and scarlet fever 
differed from each other ; and for the purpose of comparison, I 
laid down certain grounds, as those on which we founded our 
belief in the non-identity of the two last-named diseases. Those 
grounds were : — 

1. In the vast majority of cases, the general symptoms differ ; 
i. e., of smallpox and scarlet fever. (This holds equally true 
with respect to the general symptoms of typhoid and typhus 
fever.) 

2. The eruptions, the diagnostic characters, if present, are 
never identical ; •'. e., in smallpox and scarlet fever. (The par- 



320 TYPHUS FEVER. 

ticulars detailed in the foregoing papers, prove that this is as 
true of the eruptions of typhoid and typhus fever, as of those of 
smallpox and scarlet fever.) 

3. The anatomical character of smallpox is never seen in scarlet 
fever. (Just in the same way the anatomical character of ty- 
phoid fever ; i. e., lesions of Peyer's patches and the mesenteric 
glands, is never seen in typhus fever.) 

4. Both, i. e., smallpox and scarlet fever, being contagious 
diseases, the one by no combination of individual peculiarities, 
atmospheric variations, epidemic constitutions, or hygienic con- 
ditions, can give rise to the other. (I have here not attempted 
to determine how far this holds true with respect to typhoid and 
typhus fever ; but I have considered it in a paper read before the 
Medico-Chirurgical Society of London, December, 1849, the 
contents of which I may anticipate so far as* to state, that to my 
mind the origin of the two diseases from distinct specific causes 
is as clearly proved as that scarlet fever and smallpox arise from 
distinct specific causes.) 

5. The epidemic constitution favorable to the origin, spread, 
or peculiarity in form or severity of either, i. e., smallpox and 
scarlet fever, has no influence over the other, excepting that 
which it exerts over disease in general. (The facts detailed in 
these papers, prove that this holds as true of typhoid and typhus 
fevers, as of smallpox and scarlet fever.) 

If, then, the above are the grounds — and, after mature delib- 
eration, I am able to assign no others, for the separation of small- 
pox from scarlet fever, I think it is indisputably proved, that 
typhoid fever and typhus fever are equally distinct diseases ; not 
mere varieties of each other, but specifically distinct ; specific 
distinction being shown in typhoid and typhus fevers, as in small- 
pox and scarlet fever, by the difference of their symptoms, course, 
duration, lesions, and cause." 1 

In further proof of the non-identity of typhoid and typhus 
fever, Dr. Jenner has published some very striking facts in rela- 
tion to their local origin. Between May 1847, and November 
1849, there were sixty-eight instances, in which from two to five 
persons with typhoid or typhus fever were received into the Lon- 
don Fever Hospital from the same locality — generally from the 
same house or room. With one or two exceptions, there was no 

1 Jenner on the Identity or the Non-Identity of Typhoid and Typhus Fevers. 



DIAGNOSIS. — HISTORICAL. 321 

instance in which cases of the two diseases came from the same 
locality — the same house or room. 

In this connection, it is impossible not to be struck with the 
great fact — so extraordinary, and so utterly inexplicable, on the 
hypothesis that typhoid and typhus fever are only forms or va- 
rieties of a single disease, depending upon and originating from 
the same specific cause — that, for the long period of the last thirty 
or forty years, in the city of Paris and throughout New England, 
where this subject has been most carefully studied, only one of 
these forms of disease should have prevailed, to the entire and 
absolute exclusion of the other. 

I may remark here, that it is very important for us to bear in 
mind that great difficulties of diagnosis, in individual cases, are 
in no way incompatible with the existence of essentially and 
widely different diseases. Morbid affections, very unlike each 
other, and in most cases easily distinguishable, may, under cer- 
tain circumstances, have many things in common; and their 
symptoms may be so mixed up with each other as to render, in 
the imperfect state of our knowledge, a positive diagnosis very 
difficult or impossible ; and this without throwing any doubt upon 
the general question of the radical dissimilarity between the dis- 
eases themselves. 



21 



322 



CHAPTER IX. 

THEORY. 

It is unnecessary to make any general remarks upon this sub- 
ject after what has been said in relation to the theory of typhoid 
fever. A rational interpretation of the phenomena of typhus, of 
their connections and dependencies, is, if possible, more difficult 
than in the case of the latter disease. In typhus, there is no con- 
stant and uniform lesion of the solids, to which the symptoms can 
be referred. We certainly have here, if nowhere else in the 
nosologies, a general disease; an essential fever. In regard to 
its theory, and especially to the primary and fundamental disturb- 
ance which, in its turn, gives rise to the subsequent and con- 
nected morbid phenomena, the sum of which constitutes the dis- 
ease, British medical philosophers are mostly divided into two 
classes; the solidists and the humoralists. More strictly, we 
might call them the neuropathists and the hemopathists. The 
first maintain that the impression of the morbid poison is prima- 
rily made upon the nervous system ; the latter maintain that this 
impression is made upon the blood. I do not propose to enter 
into any history of the reasons urged by the partisans of these 
respective theories in support of their opinions, or in any way to 
discuss their merits. I may be allowed to say that an undue 
degree of importance seems to me to be attached to them by their 
authors and advocates. They are at best only explanations or 
interpretations, more or less probable, more or less ingenious, more 
or less plausible, of the phenomena of fever, and of the various 
relations of these phenomena. Sydenham's, or Huxham's, or 
Cullen's, may be as good as any of them. They are probably 
all of them more or less erroneous, they may be wholly so. 1 Let 

1 There seems to have been in the British medical mind an irresistible tendency 
to theorize in medicine, and to substitute for the careful observation of facts, 
and their rigorous analysis, the doubtful conclusions of speculative reasoning. This 
tendency is clearly enough giving way to a better spirit, and there can be no hazard 



THEORY. 323 

us remember, besides, and a consolatory reflection this is, in the 
midst of these multiform and conflicting theories, that they con- 
stitute an element in medical science of very subordinate per- 
haps questionable value. The true science of fever is in its 
appreciable phenomena and their ascertainable relations, not in 
any explanation of the nature of these phenomena and these 
relations. 

in predicting, that the next quarter of a century will witness a complete revolu- 
tion in the temper and philosophy of British medical science. No one can doubt 
this, who is familiar with the recent labors of British medical men ; and especially 
with the tone and spirit of some of their leading reviews. I may refer, without 
the imputation of invidiousness, for an illustration of what I mean, to an unpre- 
tending but most admirable article in the British and Foreign Medical Review 
for July, 1841, on the numerical method of investigation ; and to more than one 
other paper, in the same Review, containing full and frank acknowledgments of 
the immense obligations which our science owes to the labors and the example 
of Louis, to whom it is no extravagant praise to say, that the spirit of Dryden's 
couplet, so far as medicine is concerned, is as applicable as it was to the great 
expounder of true philosophy : — 

The world to Bacon does not only owe 
Its present knowledge, but its future too. 



324 



CHAPTER X. 

TREATMENT. 

I shall not enter so fully into the therapeutics of typhus as I 
have already done in ( relation to that of typhoid fever. It is 
unnecessary to do so, for two reasons ; in the first jplace, typhus 
is not a disease of very common occurrence amongst us; and, in 
the second place, although there is not by any means entire 
uniformity of opinion amongst the best and most extensive ob- 
servers in regard to the most appropriate treatment of this dis- 
ease in all its details, and under all circumstances ; still, there is 
a good degree of agreement in regard to some of the leading 
points in its management. I shall say what seems to be necessary 
to the practical understanding of this subject ; treating, in so many 
sections, of individual remedies or classes of remedies, and ar- 
ranging them somewhat, at least, in the order of importance 
which has generally been attached to them. 

Sec. I. — Bleeding. General bloodletting has been pretty 
frequently resorted to by British practitioners, in the manage- 
ment of typhus ; although there seems to have been at all times 
some practitioners more than doubtful about the propriety of this 
remedy. One very striking fact, however, is observable -in 
connection with this subject; and that is, the extreme caution 
with which bleeding is, almost without exception, recommended 
and practised. Sangradoism was never popular in the treatment 
of typhus. Amongst the older practitioners, Sydenham, Pringle, 
and Grant were bleeders ; but they were moderate bleeders, as 
most of their successors have been. 

During the early part of the present century, this operation 
seems to have been not often resorted to ; and the credit of having 
very much aided in restoring it to public confidence has been 
given to Dr. Thomas Mills, of Dublin. Dr. Mills published his 
Essay on the Utility of Bloodletting in Fever, in 1813. But 



TREATMENT. — BLEEDING. 325 

even Dr. Mills, the restorer and champion of the practice, as he 
seems to have been regarded, was what would now be considered 
a very small bleeder. His most common practice was to abstract 
from four to six ounces, and in many cases this was not even 
repeated. 

Gilbert Blane, who saw a great deal of the disease on ship- 
board, says of bloodletting that it is a remedy very ill adapted 
to this sort of fever, particularly in a hot climate. 1 

Sir John Pringle says : " The pulse is little affected by bleed- 
ing once, if a moderate quantity of blood be taken away ; but if 
the evacuation is large, and especially if repeated to answer a 
false indication of inflammation, the pulse increasing in fre- 
quency, is apt to sink in force and often irrecoverably, whilst the 
patient becomes delirious." 2 "Many recovered without bleed- 
ing," he adds, "but few who lost much blood." 

Dr. Edward Percival recommends bleeding, where there is 
pneumonic complication, to the extent of from eight to fourteen 
ounces ; and says that sometimes, though rarely, it may be re- 
peated once or twice. He cautions his readers against large 
bleedings, and says that patients will sink under them. Dr. 
O'Brien bled early to the extent of from six to eight ounces, and 
repeated the process, if necessary, once or twice. Dr. Grattan. 
and this only when the lungs were affected, adopted the same 
cautious practice. In one hundred and sixteen patients whom he 
bled at the Cork Street Hospital, in 1818, the average quantity 
of blood taken from each was only five and a half ounces. Dr. 
John Cheyne, of Dublin, had the reputation of being a free 
bleeder ; but he also was cautious. He says that he has known the 
operation to destroy life ; and that there are many cases of the dis- 
ease in which, during all their stages, it is wholly inadmissible. His 
average quantity at a bleeding was only ten ounces, and he rarely 
exceeded twelve. When more than this amount was to be taken, 
he considered it his duty to be present, and to superintend the ope- 
ration. Dr. Armstrong recommends one or two moderate bleed- 
ings early in the fever, when it is complicated with local in- 
flammation. Dr. Southwood Smith is one of the most liberal 
bleeders amongst recent British writers on typhus. But his 

1 Obs. on Dis. of Seamen, p. 363. 

2 Obs. on Dis. of Army, p. 257. 



326 TYPHUS FEVER. 

practice is founded on an assumption doubly gratuitous ; first, that 
inflammation is in all cases the morbid condition which is to be 
removed ; and secondly, that it is the only morbid condition in 
typhus fever over which we have any control. The phraseology 
of his directions for bleeding is, as it always is, clear, distinct, 
and emphatic ; but the ideas contained in his eloquent words are 
not so manifest and intelligible as might be wished. He insists 
upon the necessity of bleeding till local pain is not diminished 
only, but removed ; till inflammation is not merely mitigated, but 
subdued. The mere mitigation of inflammatory action by bleed- 
ing he even thinks is more hurtful than beneficial. Dr. Smith 
seems to have changed his notions about the utility of bleeding. 
He informed the author, in the summer of 1846> that, at the Lon- 
don Fever Hospital, bleeding had been performed only four times 
during the then plst year, and twice by mistake. Dr. William 
Henderson's admirable account of the typhus fever of Edinburgh, 
in 1838 and 1839, has already been frequently referred to. His 
analysis of the results of his treatment is especially valuable. 
Of ninety-six females admitted into the Infirmary during a given 
period of time, thirty-six were bled from the arm, and the average 
quantity taken from each patient was twenty ounces. The cir- 
cumstances which were looked upon as indicating the propriety 
of bloodletting were — that the fever should not have been in an 
advanced stage, the individual not of a delicate or previously 
enfeebled constitution, the pulse at least firm whether small or 
full, and either particular local suffering or general pains, rest- 
lessness, and flushing. In three instances, some of the most 
important of these indications were wanting; and two of the 
three were fatal. The average duration of the cases that were 
bled and recovered, up to the commencement of convalescence, 
was eleven days and two-thirds, and the mortality was one in 
eighteen. Fifty-two other female patients, also admitted suc- 
cessively during a given period, who were not bled, gave a 
mortality of one in ten ; and the average duration of these cases, 
excluding those of a milder character, in which no wine was 
given, was fifteen days and a half. 1 In the Philadelphia typhus 
of 1836, bloodletting was rarely practised, and did 'not appear to 
be well borne. 

1 Eclin. Med. and Surg. Journal, Oct. 1839. 



TREATMENT. — BLEEDING. 327 

The immediate effects of bleeding seem to be much more ob- 
vious and decided in typhus than they are in typhoid fever. 
Thus, of one hundred and forty-nine patients, in whom this means 
was resorted to by Dr. Cheyne, in 1816, ninety-four experienced 
immediate relief. In nearly all the cases treated at Edinburgh, 
by Dr. Henderson, in 1838 and 1839, the operation of blood- 
letting was followed by speedy relief, or removal of the local 
pains, and frequently by a mitigation in the severity of other 
symptoms. 

The conclusions to which we come, then, in regard to this im- 
portant practical matter are these : first, that general bloodletting 
to a moderate extent, repeated once or twice, if the indications 
call for it in the early period of the disease, especially in cases 
where the previous health of the patient had been sound, where 
the pulse is somewhat hard, and where there is severe local pain, 
constitutes a remedy of great and unquestionable value ; that it 
mitigates the severity, shortens the duration, and lessens the mor- 
tality of the disease ; secondly, that this remedy is always to be 
used with great caution ; that there is an unknown element in the 
pathology of typhus fever, which renders this caution always 
necessary, and which, under many circumstances and in many 
cases, renders the remedy wholly inadmissible. Amongst the 
contraindicating circumstances may be mentioned the advanced 
stage of the disease ; previous debility or ill health of the patient ; 
a constitution impaired by excesses, and particularly by that of 
dram-drinking ; the absence of the special indications for blood- 
letting which have already been enumerated ; and, finally, the 
predominance of the congestive or typhoid state, characterized 
by the extreme prostration of strength, feebleness of the pulse, 
and torpor of the surface which marks the disease more or less 
strongly during certain seasons. It ought to be added here, that 
some of the Irish and Scotch practitioners do not resort to the use 
of bloodletting at all in the treatment of typhus. Amongst these 
may be mentioned Dr. Mateer, and Dr. Little, both of Belfast. 
They seem to consider the disease as essentially one of debility. 
Dr. Graves, also, thinks that the proportion of cases in which 
general bloodletting can be practised with advantage and safety 
is small. 

Local bloodletting may be resorted to with very uniform benefit. 
There is great unanimity of opinion, in regard to the safety and 



328 TYPHUS FEVER. 

the usefulness of this remedy. Scarified or dry cups, applied to 
the nucha or along the spine between the shoulders, have been 
found of great efficacy in removing or diminishing the suffusion 
of the eyes, the injection of the face, the headache, the delirium, 
and other symptoms. They constituted in nearly all the cases 
a part of the treatment pursued by Dr. Gerhard, at Philadelphia, 
in 1836. Speaking generally of dry cups, he says: " Applied 
in considerable numbers, and left upon the nape of the neck and 
between the shoulders, for twenty minutes or half an hour, they 
always seemed to me a more powerful remedy in nervous func- 
tional derangement not attended with inflammation than scarified 
cups. I have used them largely in the treatment of the apoplectic 
symptoms of malignant intermittent with the best effects, and re- 
sort to them with confidence as one of our most powerful means 
of controlling disordered nervous action." 

Sec. II. — Purgatives. The use of purgatives in typhus fever 
by British physicians has been almost universal. At one of the 
Dublin Fever Hospitals, under the care of Dr. Cheyne, it was 
formerly one of the standing directions for the nurse to administer 
immediately to a newly-received patient, two pills composed of 
one grain each of calomel, scammony, and aloes ; the pills to be 
followed in three or four hours with a purgative mixture. Nearly 
all the Irish writers reckon purgatives second only in importance 
to bloodletting, and much more generally applicable than this 
remedy. Some of them rely almost wholly upon them, and upon 
the ordinary hygienic measures, applicable to most febrile dis- 
eases. They recommend that mild purgatives, especially during 
the early periods of the disease, should be so administered and 
continued as to procure two or three discharges from the bowels 
daily. A small quantity of calomel usually enters into the com- 
position of the purgative, although the action of the mercury 
upon the mouth is not generally considered desirable. From an 
examination of the opinions of the best modern observers, it is 
quite clear, I think, that active and drastic purging is to be 
avoided. 

Sec. III. — Affusions and Ablutions. The agreement of opinion 
and practice in regard to the external use of water at different 
temperatures, according to circumstances, is hardly less general 



TREATMENT. — STIMULANTS. 329 

than it is in relation to the necessity of purgatives. Dr. Pcrcival 
used the cold affusion, especially in the treatment of children ; 
pouring several gallons of cold water from a bucket, over the 
head and body. On account of the inconvenience of thi3 mode, 
and for other reasons perhaps, the process of ablution or spong- 
ing has generally been preferred. When the skin is uniformly 
hot and dry, the water maybe applied in this manner quite cold; 
but if the temperature is not much elevated, or if there is slight 
or partial perspiration, it is safer and better that it should be 
tepid. Dr. Gerhard says that, by frequent sponging, he found 
that he could regulate the heat of the surface with great ease, and 
in some degree also could moderate the cerebral symptoms. Dr. 
Graves, of Dublin, has found that the pain in the head, and other 
symptoms of over-excitement in the brain, are often more speedily 
and effectually relieved by applying fomentations of hot water 
than they are by the common cold applications. This is in 
accordance with the extensive experience of my friend and late 
colleague, Dr. Dudley, of Lexington, Ky., in the similar treatment 
of many local affections of a painful or inflammatory nature. 

Sec. IV. — Stimulants and Tonics. The almost uniform expe- 
rience of British observers has sanctioned the use of stimulants 
in the treatment of this disease ; and, amongst the individual 
articles of this character, a very general preference has been 
given to wine. Some of them urge its administration earlier in 
the fever than others, and in more liberal quantities ; but none 
of them, so far as I know, dispense with it altogether. Dr. 
Stokes, of Dublin, said, in 1839 : " I feel certain, humiliating 
though the confession may be, that the fear of stimulants in fever 
with which I was imbued was the means of my losing many 
patients, whose lives would have been saved, had I trusted less 
to the doctrine of inflammation, and more to the lessons of expe- 
rience, given to us by men who observed and wrote before the 
times of Bichat and Hunter." 1 "When the cutaneous circulation 
is languid and the skin not hot, when the pulse is soft and feeble, 
and there are great exhaustion and debility, at whatever stage of 
the disease, there can be no doubt as to the necessity of the stim- 
ulating and supporting treatment. During some epidemics, 

1 Dub. Journ. of Med. Sci., March, 1839. 



330 TYPHUS FEVER. 

when the adynamico-congestive element in the pathology of 
typhus is marked and predominant, this condition of the system 
will often be present at the commencement of the fever, and will 
require the early use of stimulants and tonics. More commonly, 
however, this state of things attends the later period of the dis- 
ease, coming on as the febrile excitement subsides ; and then it 
must be met by the same remedies, with an activity and assiduity 
commensurate with the urgency of its symptoms. Br. Gerhard, 
in his account of the Philadelphia epidemic of 1836, says : " It 
is difficult to conceive the extreme prostration in which our 
patients were left after a severe attack of fever. The skin is 
usually cool, and the pulse weak and fluttering, but there are 
still muttering delirium and great feebleness. Under these cir- 
cumstances, wine, combined with quinine, and a nutritious diet, 
produced an effect which was almost magical." Dr. Stokes 
thinks that, in addition to the ordinary indications for the 
use of wine in typhus, may be placed want of energy in the 
action of the heart, as shown by its diminished impulse, and 
the feebleness or extinction of the first sound. He says 
that the existence of these phenomena, at an early period 
of the disease, has sometimes led him " to anticipate the 
bad symptoms, and to commence in good time the use of the 
great remedy ;" and that, " in others, notwithstanding the exist- 
ence of severe visceral irritations, the use of stimulants has been 
adopted with the best success from the same indication." 1 It 
does not appear to be necessary that wine should be given in 
very large quantities. The daily amount used by Dr. Gerhard, 
varied from four to sixteen ounces ; in most cases from six to 
eight. 

The only other articles belonging to this class of remedies, of 
which it is necessary to speak particularly, are the preparations 
of cinchona. Dr. Gerhard, in the latter stages of the disease, 
during the Philadelphia epidemic, and under the same circum- 
stances that indicated the necessity for wine, employed the sul- 
phate of quinine, given in solution, to the extent of about twelve 
grains in the twenty-four hours. Speaking of tonics generally, 
he observes : " They not only exercised a gradual and permanent 
influence upon the appetite and strength of the patient, but they 

i Dub. Journ. of Med. Sci., March, 1839. 



TREATMENT. — MISCELLANEOUS REMEDIES. 331 

produced an immediate impression. The improvement was some- 
times so rapid, that it was very obvious from one day to the 
next." Amongst the means for restoring, temporarily at least, 
the exhausted and flagging energies of the system, may be in- 
cluded the external application of dry heat, and the use of sina- 
pisms. Dr. Gerhard says of these latter : " They were of great 
and undoubted advantage in the stage of prostration, which 
occurs at the decline of the fever, and certainly contributed to 
save the lives of several of our patients." He also found them 
useful in diminishing the stupor and prostration during the dis- 
ease, as well as in reanimating the strength of patients who were 
brought to the hospital, exhausted from neglect, and a fatiguing 
ride from a distant part of the town. But if the fever was high, 
and the heat of the skin considerable, sinapisms were vastly less 
effectual than when the skin was cool and the patient seemed sink- 
ing from mere exhaustion. 

Sec. V. — Miscellaneous Remedies. It would be an irksome 
and not very useful task to enumerate all the articles which have 
by one observer and another been recommended under certain 
circumstances and for the purpose of answering peculiar indica- 
tions. I will briefly mention some few of these, the efficacy of 
which has been best established. 

Diaphoretics seem to be of considerable service, in allaying the 
intensity of febrile excitement. Dr. Little, of Belfast, classes 
them amongst his most useful remedies. The most powerful of 
these has already been spoken of ; I mean the cool and tepid 
ablution of the body. Amongst the most unexceptionable perhaps 
of those to be used internally, are the effervescing draughts, and 
the liquid acetate of ammonia. 

When bronchitic or pneumonic complications have not been 
removed by the remedies already spoken of, resort may be had 
to vesication, and to the guarded use, internally, of ipecacuanha 
and antimonials. In some cases, where the bronchial secretion 
was very abundant, Dr. Henderson found great benefit from the 
administration, several times a day, of from half a grain to two 
grains of the acetate of lead, combined with a small quantity of 
Dover's powder, and one or two grains of squill. Dr. Graves, of 
Dublin, has made use of antimony in the treatment of typhus, 



332 TYPHUS FEVER. 

under peculiar circumstances, the credit of which novelty he 
claims as entirely his own. 1 In the latter stages of the disease, 
when there are in addition to other symptoms great prostration 
of strength, and extreme nervous restlessness and sleeplessness, 
he gives tartar emetic, in solution with camphor mixture and 
combined with laudanum. Six grains of the antimony are given 
in the course of the twenty-four hours. This combination, under 
these circumstances, he thinks possesses an almost magical power 
in allaying the nervous restlessness, and in procuring sleep. 

In regard to the utility of emetics, there is some difference of 
opinion. They have been mostly used under two circumstances; 
first, at the very commencement of the fever ; and secondly, when 
a relapse or an aggravation of the symptoms has been threatened 
at or near the beginning of convalescence, occasioned by some 
indiscretion of diet. Dr. Gerhard thinks that they were useful 
at Philadelphia, in 1836, in diminishing the violence of the 
fever. Dr. Graves speaks very highly of their efficacy, and very 
confidently also of their power, if administered within the first 
twenty-four hours from the time of seizure, of wholly arresting 
the disease. 

Camphor and opium are amongst the articles which have been 
extensively used for the purpose, principally, of allaying nervous 
agitation and restlessness, and inducing quiet and sleep. As a 
general rule, they seem to be most effectual in accomplishing these 
purposes, when the general febrile excitement is not very great, 
and when there are no indications of irritation, or congestion of 
the brain. I shall conclude these directions for the treatment of 
typhus, with Dr. Gerhard's remarks upon these two substances. 
"Camphor," he says, "was certainly amongst the most useful 
and powerful of our remedies. We used it largely in the severe 

1 Graves's Clinical Lectures, p. 130, et seq. 

2 Sir Gilbert Blane says: " The head being particularly affected in this sort of 
fever, the patient is extremely restless and delirious, especially at night ; and there 
is a medicine which has a most pleasing effect in procuring both rest and perspira- 
tion. This is a combination of an opiate with an antimonial medicine, which was 
administered in the evening with great success." — Obs. on Dis. of Seamen, p. 367. 

The same excellent observer and philosophical physician remarks again : "In 
this advanced stage of the fever, in which the most common symptoms are weak- 
ness, restlessness, tremors, and low delirium, no medicine was found so much to 
be trusted to as opium, which here acts as a cordial as well as an anodyne and 
antispasmodic." — Ibid., p. 380. 



TREATMENT. — OPIUM. 333 

cases, especially those in which the ataxic nervous symptoms 
were very marked ; and we had no reason to repent its employ- 
ment. In general, there was a marked diminution of some of the 
most prominent and harassing symptoms. We gave the camphor 
in emulsion in doses of five grains every two hours, and in enema 
in doses of a scruple. The immediate effect was the lessening of 
the subsultus and tremors, for which it was chiefly administered, 
and sometimes the diminution of delirium. In some cases, we 
possessed a complete control over the subsultus, which was im- 
mediately checked by an injection containing a scruple of cam- 
phor. It would cease for some hours, but afterwards return 
nearly with its former severity. Still, it was a useful palliative, 
and, like most remedies of its class, acted as a useful balance- 
wheel in preserving the harmony of the system until the disease 
had passed through its natural course. The camphor frequently 
acted powerfully as an anodyne, when sleep had been interrupted 
by the previous disturbance of the nervous system." 

Huxham is high in his praise of camphor. " Its anodyne 
demulcent quality," he says, "makes it vastly serviceable in 
quieting the Erethism, and bringing on composure of spirits 
and easy sleep, when opiates fail, nay augment the tumult and 
hurry." 

" Opium and its preparations," continues Dr. Gerhard, " were 
used by us in a considerable number of cases. Dr. Pennock was 
the most pleased with their effects. When the insomnia had been 
tormenting and incessant, and the patient was exhausted by agi- 
tation and nervous restlessness, a small dose of morphia would 
generally calm the agitation and procure sleep. This advantage 
was so great, that we were induced to give opiates in cases which 
were opposed to our ordinary notions of the proper condition of 
the system for their employment. We observed no inconvenience 
from them, and found the morphia occasionally of so much benefit, 
that we should class it amongst the decidedly useful remedies. It 
is not a remedy which should be used in large doses; as patients 
with typhus are certainly more readily affected by its narcotic 
properties than they are in any other disease. An eighth or a 
sixth of a grain was the usual dose, and was enough to procure 
sleep. Opiates are obviously improper, when there is much dul- 
ness of intellect, attended with great suffusion of the eyes and 
countenance." Another positive contraindication to the use of 



334 TYPHUS FEVER. 

opium, first pointed out and insisted upon by Dr. Graves, of Dub- 
lin, is to be found, according to this writer, in a contracted state 
of the pupil. When this is present, he thinks opium is always 
injurious. Reasoning from the effects of belladonna in occasion- 
ing dilatation of the pupil, Dr. Graves was led to suppose that, 
given in cases of typhus attended with contraction of the pupil, 
it might remove the unknown condition of the brain upon which 
the contraction depends; and he says that he has used it repeat- 
edly, under these circumstances, with very satisfactory results. 1 

The diet, when the fever begins to decline, should be somewhat 
more nutritious and supporting than under the same circum- 
stances in typhoid fever. The contagious character of the disease 
should be borne in mind, and every means taken to prevent a 
concentration of its peculiar poison. It seems hardly necessary 
to insist upon the paramount importance of cleanliness, free ven- 
tilation, quiet and good nursing. There is no disease in which 
all these are more essential to the welfare and safety of the pa- 
tient than they are in this. 

The question of the positive efficacy of active medical treat- 
ment in diminishing the duration of fever and in interrupting its 
course, was examined in a most fair and philosophical spirit, in 
a very accurate manner, by William Brown, M. D., of Edinburgh, 
in a paper which may well be cited as a model for similar inves- 
tigations, contained in vol. vii. of the "Annals of Medicine," 
for the year, 1802, edited by Drs. Duncan, Sen. and Jun. Dr. 
Brown shows, very clearly and conclusively, that the powers of 
medical treatment in arresting the disease, or in shortening its 
duration, are to say the least very doubtful or very small. 

Hildenbrand says: " In this disease, our treatment can only be 
of benefit in an indirect manner ; that is, in concert with the salu- 
tary efforts of the vital powers. No method yet known, whether 
rational or empirical, can cure the contagious typhus, either in a 
direct or an indirect manner ; nor even abridge its ordinary and 
natural course, which is about fourteen days." 2 

1 Dub. Jourr. of Med. Sci., July, 1838. 2 Gross's Hildenbrand, p. 94. 



335 



CHAPTER XI. 

DEFINITION. 

This disease, in the present state of our knowledge respecting 
it, may be defined in the following terms: Typhus Fever is an 
acute affection, occurring at all ages of life ; attacking, at least in 
cities, somewhat more frequently persons who are recent than 
those who are old or permanent residents; often transmitted 
directly from one individual to another ; very much more common 
in the British islands than anywhere else, although prevailing at 
times in other countries, generally in the form of circumscribed 
epidemics; often connected with the crowding of many persons 
into small, dark, and poorly-ventilated apartments, amidst filth 
and destitution ; frequently sudden, but sometimes gradual in its 
access ; attended at its commencement with chills, usually slight 
and in many instances repeated; then with morbid heat of the 
skin, in many cases very intense and pungent ; with increased 
quickness, with softness and feebleness of the pulse; with accele- 
rated respiration ; in many cases with the physical signs of bron- 
chitis and pulmonary congestion ; with pain in the head, back, and 
limbs; dulness or perversion of the powers of the mind; drowsi- 
ness or stupor ; dizziness, deafness, and ringing or buzzing in the 
ears ; morbid sensibility of the skin and muscles on pressure ; ex- 
treme prostration of muscular strength ; spasmodic twitchings of 
certain muscles ; dull and stupid expression of the countenance ; 
fuliginous flush of the face; suffusion of the eyes; with loss of 
appetite and with thirst ; sometimes with a slightly altered tongue, 
but in grave cases, with a dry, red, brown, or black and fissured 
state of this organ ; sordes upon the teeth and gums ; occasional 
nausea and vomiting; frequently with a constipated or sluggish 
state of the bowels ; the skin of the body and extremities being 
generally the seat of an abundant eruption, coining out in most 
ca^es between the fourth and seventh day of the disease, and de- 
clining at uncertain periods during the second and third week, 



336 TYPHUS FEVER. 

consisting of small spots, generally somewhat obscurely defined, 
and irregularly shaped, not unfrequently grouped and confluent, 
of a dusky, dingy red color, not elevated above the surrounding 
surface, and disappearing only imperfectly or not at all on pres- 
sure ; the body of the patient in grave cases giving out a pungent, 
offensive, and ammoniacal odor ; which symptoms differ very widely 
in their duration, in their march, in their severity, and in their 
combinations, in different cases ; several of them being frequently 
wanting, but enough of them being generally present to charac- 
terize the disease ; the most constant of which are the loss of 
strength, the stupor, the suffusion of the eyes, the fuliginous skin, 
and the dusky cutaneous eruption; which symptoms may either 
gradually diminish in severity, and finally disappear between the 
seventh and thirtieth day of the disease, or may increase in seve- 
rity and terminate in death between the third and twentieth day 
from their access ; the liability to a fatal termination being much 
less early than late in life : the bodies of patients exhibiting, on 
examination after death, no constant pathological changes of any 
of the organs ; but, in a considerable though varying proportion 
of cases, engorgement of the vessels of the brain with moderate 
sub-arachnoid serous effusion; engorgement of the posterior por- 
tion of the lungs ; redness of the mucous membrane of the bron- 
chia ; softening or mamellonation of the mucous membrane of the 
stomach ; the blood being generally of a dark color, often fluid or 
grumous ; the coagula when formed, soft and non-fibrinous ; and 
the body in many cases running rapidly into decomposition ; — 
which disease, thus characterized and defined, constitutes a pecu- 
liar individual affection, differing essentially from all others, al- 
though related by many analogies to typhoid fever. 



337 



CHAPTER XII. 

BIBLIOGRAPHY. 

For reasons which must be sufficiently obvious, the literature 
of typhus fever is mostly British. I shall enumerate only those 
original treatises which have fallen in my way, and which I have 
used, more or less freely, in making up -the preceding history. 

Observations on the Diseases of the Army. By Sir John 
Pringle. Dr. Rush's edition. Philadelphia, 1810. Pringle was 
attached to the British army, in the Low Countries, from 1742 to 
1745, and also in 1747 and 1748. His experience as an army 
physician was mostly confined to this period of his life. The 
only portion of the observations of which it is proper to speak 
particularly here, is that relating to the jail, or hospital fever. 
This is short, occupying together with a reply to De Ilaen, only 
sixty pages, but worth its weight in gold. His general descrip- 
tion of the disease, in six pages, is ' capital. His clear and un- 
equivocal recognition of the specific and essential difference be- 
tween the two great forms of continued fever, typhus and typhoid 
— called by him jail or hospital fever, and miliary fever — has 
already been referred to. 

Medicina Nautica: an Essay on the Diseases of Seamen, etc. 
By Thomas Trotter, M. D., etc. London, 1803. This is a some- 
what famous book — rambling, desultory, and egotistical ; flaming 
with patriotism, as it ought to be, since its materials were "gleaned 
amidst the laurels of the British navy, and protected by its ban- 
ners ;" sprinkled with his personal difficulties with his subordi- 
nates and superiors, and sneers at Dr. J. Carmichael Smyth's 
nitrous fumigation, which he calls " a mock-heroic placebo" for 
destroying bad smells — but withal rather an agreeable and racy 
book, whose leaves one can at least turn over with some pleasure 
and a little profit. Dr. Trotter saw much of true typhus as it 
originates and prevails on shipboard. The origin of typhus on 
22 



338 TYPHUS FEVER. 

board crowded ships seems very analogous to its frequent occur- 
rence in Irish cabins. 

A Treatise on the Nature, Cause, and Treatment of Contagious 
Typhus. From the German of J. Veil, de Hildenbrand. By S. 
D. Gross, M. D. New York, 1829. Hildenbrand had extensive 
opportunities for the study of typhus fever, during the latter part 
of the last, and the early part of the present century, in the 
German armies connected with the wars of that period. His work 
is an elaborate and systematic monograph on that disease. Its 
great fault is that it is over systematic ; there is no disease in the 
nosology so fixed, and constant, and uniform in its phenomena 
— in its symptoms, changes, march, and duration — as his simple 
regular typhus. "On the fourth day," he says, "there is gene- 
rally a slight degree of hemorrhage from the nose ; critical exacer- 
bations take place exactly at the end of the third, and at the 
commencement of the seventh day ; and subsequently at the end 
of the tenth and at the beginning of the fourteenth day," and so 
on. He divides the disease into eight periods. The fever which 
fell under his observation was probably mostly typhus, mingled, 
however, I think, more or less, with typhoid. This celebrated 
work is certainly not without its interest, but it has less positive 
value than I had been led to expect before reading it. In allusion 
to the different and opposing methods of treatment which have 
been advocated and employed in typhus, he quotes the adage — 
Pessima medendi methodo non omnes trucidantur. 

An Essay on the Utility of Bloodletting in Fever, etc. By 
Thomas Mills, M. D. Dublin, 1816. The object of this work is 
indicated by its title. Dr. Mills not only makes no distinction 
between the different forms of fever — continued, periodical, and 
so on — but he even confounds with fever various local inflam- 
mations. This radical defect in regard to diagnosis, renders the 
book entirely worthless. 

Observations on the Prevention and Treatment of the Epidemic 
Fever at present prevailing, etc. By Henry Clutterbuck, M. J). 
London, 1819. This book is made up, in a good degree, by an 
application of the author's theoretical views of the pathology of 
fever to the treatment of this disease. His work, containing a 
statement of these views, was published as early as 1807. He 
regards fever as an inflammation of the brain, and so far as there 
is any merit in having started the doctrine of the local inflamma- 



BIBLIOGRAPHY. 339 

tory origin of fevers, it belongs more to Clutterbuck than to Brous- 
sais. There is a good deal of reasoning and criticism in the 
book ; but it is always courteous and good-tempered. The most 
frequent form of fever in London, during the prevalence of the 
epidemic, was that corresponding to the sloiv nervous fever of 
Huxham. He doubts whether the prevalence of fever is as directly 
dependent upon insufficient food and crowded and close dwellings 
as is commonly supposed. Dr. Clutterbuck evidently feels that 
he has done a signal service to medicine by founding the practice 
of bloodletting, in fever, upon what is called a rational indication 
or a principle ! thus freeing it from the reproach and disgrace of 
being merely an empirical remedy ! Alas, for the blindness and 
fatuity of this miserable and false philosophy! Strongly as he 
relies upon bloodletting, he is constantly insisting upon the 
necessity of great caution and discrimination in its use. This 
seems to have been forced upon him by his experience, in spite 
of the pleadings of his theory. The book is vitiated throughout 
by the hypothetical assumption in regard to the nature of fever, 
and it adds little or nothing to our knowledge of the disease. 
An Account of the Rise, Progress, and Decline of the F< 
lately epidemical in Ireland, etc. By F. Barker and J. Cheyne. 
2 vols. London and Dublin, 1821. This work is a systematic 
and documentary history of the great Irish epidemic of 1817, 1818 
and 1819. It is one of the most substantial and valuable general 
histories of disease that has ever been written: a proud and 
worthy monument of Irish science, humanity, and skill. It con- 
sists, in great part, of communications relating to the epidemic, 
made by the leading medical men of all parts of the country. No 
one can read these papers without being forcibly struck with the 
high qualities of the Irish medical mind: its sagacity, its clear 
common sense, its accurate observation, and, compared with that 
of its sister island, its freedom from the corrupting influences of 
systems and hypotheses. 

Jin Historic Sketch of the Causes, Progress, Extent, and Mor- 
tality of the Contagious Fever epidemic in Ireland during the 
years 1817, 1818, and 1819. By William Harty, 31. B. 
Dublin, 1820. The objects of this work are sufficiently stated 
in its title. It is in every way a worthy companion to the 
history, by Dr. Barker and Dr. Cheyne. It is written with 
elegance, earnestness, and ability ; and it constitutes another of 



340 TYPHUS FEVER. 

the many evidences of the signal excellence of the Irish medical 
mind. Dr. Harty does not profess to detail the symptoms and 
treatment of typhus ; but he enters very fully into a consideration 
of its causes. His views upon this subject are marked by the 
soundest judgment and good sense. He insists, with entire 
conclusiveness, upon the action of many concurrent causes, in 
its production ; and he opposes, with equal success, the doctrines 
of systematists and exclusives. Contagion, war, famine, want of 
employment, personal and local uncleanliness, unventilated and 
crowded dwellings, are the chief amongst these concurrent causes 
— acting, in some instances singly, but more generally together. 

A Succinct Account of the Contagious Fever of this Country, 
etc., by Thomas Bateman, M. D., F. L. S., etc. London, 1818. 
This is another of the many valuable essays growing out of the 
great epidemic of 1817, 1818, and 1819. Dr. Bateman was a 
good observer, in the British sense of that term, and a sound 
practitioner. The value of his book is greatly impaired by the 
absence of all distinction between the typhoid and typhus forms 
of continued fever — both of which, but principally the former, it 
is very evident, were present at the period of which he writes. 
He is over positive in his conclusion, that epidemic fevers always 
depend upon scanty and poor food. He insists strongly upon 
the essential identity of all forms of continued fever. He speaks 
particularly of the connection between troublesome diarrhoea and 
protracted cases of the disease — clearly enough cases of typhoid 
fever. In three autopsies, he found ulceration of the small intes- 
tines ; and asks if they might not have been produced after death 
by putrefaction, or by the action of the acrid contents of the 
bowels ! He insists strongly on the advantages of the cooling 
and antiphlogistic treatment, and dislikes antimony and opium. 
The last chapter is upon the subject of contagion. Its principal 
objects are to show that the fever is less contagious than had 
been generally supposed; that the poison extends only a short 
distance from the sick; that dilution with fresh air renders it 
harmless; and that muriatic acid fumigation acts to the same 
end. 

A Sketch of the History and Cure of Contagious Fever. By 
Robert Jackson, M. D. London, 1819. This work on typhus is 
by the famous author of the treatise on the fevers of the West 
Indies. It is mostly made up of short and very loose accounts 



BIBLIOGRAPHY. 341 

of typhus fevfcr, as it occurred during the latter part of the last, 
and the early part of the present century, in various portions of 
the British army and navy. It is of small value. 

Practical Observations on the Treatment, Pathology, and Pre- 
vention of Typhus Fever. By Edward Percival. Bath, 1819. 
This little monograph was written hy Dr. Percival after his 
removal from Dublin to Bath. His description of typhus is 
pretty full and pretty good. Some of his conclusions arc loose 
and hasty; those, for instance, in regard to the connection of 
certain forms and modifications of fever with season and weather. 
He says he is an advocate for the humoral rather than the nervous 
pathology of fever. The book is vitiated throughout by a spu- 
rious a priori philosophy. Dr. Percival concludes with that 
stereotyped motto of medical books — " Opinionum commenta 
delet dies, naturae judicia confirmat." 

A History of the Ejndemic Fever which prevailed in Bristol 
during the years 1817, 1818, and 1819, etc. By J. C. Priclutr<l, 
M. D. London, 1820. This is another of the many local his- 
tories which were written by British practitioners of the last great 
epidemic. The author's description of the fever is sketchy ami 
imperfect. He considers it entirely settled that typhus often 
originates spontaneously, from unknown causes, and also that 
it is frequently communicated, directly, by contagion. He takes 
strong ground for the old doctrine of a pestilential constitution 
of the atmosphere, favoring the prevalence of certain diseases 
during certain periods of time. " For explaining such phe- 
nomena," he says, " it is not sufficient to trace an infected ship 
to a particular spot, or to smell out a bog on a piece of marshy 
ground near some particular town." 

Dr. Prichard's style is excellent, clear, strong, correct, and 
always to the point. 

Be Videntite du Typhus et de la Fievre Typhoide. Par C. E. 
S. G-aultier de Claubry. Paris, 1844. 1 vol. pp. 496. The 
Identity of Typhus and of Typhoid Fever. By C. E. S. G-aultier 
de Claubry. 

The French Royal Academy of Medicine proposed, in 1835, 
as the subject of one of its annual prizes, to be awarded in 1837, 
" The analogies and the differences between typhus and typhoid 
fever." Instead of the prize thus offered, two prizes of encourage- 
ment were given by the Academy, the first to the work above 



342 TYPHUS FEVER. 

named, in which the identity of the typhoid fever of modern 
French writers and the typhus of camps and jails is maintained, 
and the second to M. Montault, for an Essay advocating the 
opposite doctrine. Both essays were ordered to be published in 
the Memoirs of the Academy. This work of M. de Claubry is 
the second edition of his prize memoir, enlarged and completed. 

My own opinion in regard to this matter was very briefly but 
explicitly expressed in the first edition of my work. I do not see 
any occasion to change it. M. de Claubry has collected from 
various sources, histories, more or less complete, of fevers prevail- 
ing in camps, barracks, and prisons, in different localities on the 
continent of Europe, mostly between the years 1804 and 1815. 
In many instances, these fevers correspond very exactly to ty- 
phoid fever; in others, they correspond to typhus. M. de 
Claubry insists upon the general presence, in these fevers of the 
continent, called typhus, of diarrhoea, and tympanitic abdomen, 
and in the existence also of intestinal ulceration. It is very 
important to remember, that, in this discussion, he expressly sets 
aside the question of the existence of a separate disease — the 
British typhus — characterized by the general absence of diarrhoea 
and of intestinal lesions. Louis is often quoted as authority for 
the doctrine of the identity between the camp and jail fevers of 
the continent, and typhoid fever, and rightly enough ; but he has 
repeatedly and explicitly declared his belief that the British 
typhus, occurring with nearly the same frequency, at different 
periods of life, rarely attended with any prominent abdominal 
symptoms, and not characterized by any intestinal lesion, is fun- 
damentally and essentially unlike the typhoid fever of his own 
researches. 

Natural History, Pathology, and Treatment of the Epidemic 
Fever, at present prevailing in Edinburgh and other towns. By 
John Rose Cormack, M. D. London, 1843. There prevailed at 
Edinburgh, in the course of the year 1843, a form of fever, 
differing, in many respects, from the common typhus of the 
country, and resembling, in some respects, the yellow fever of 
hot climates — particularly in the presence of yellowness of the 
skin, and, in some cases, of black vomit, and hemorrhages. The 
whole character of the epidemic seems to me to be so questionable 
and anomalous as to render it difficult for us to assign it its true 
position. Certainly, it was not the genuine yellow fever, and 



BIBLIOGRAPHY. 343 

many of the features of true typhus were wanting. This I sup- 
pose was the new Relapsing Fever of British writers. 

The article on Fever, in the Library of Practical Medicine, is 
by Dr. Christison, of Edinburgh. He patriotically adheres to the 
old Cullenian division of fever into Synocha, Synochus, and Ty- 
phus. Dr. Christison makes the common mistake of attributing 
to Louis the opinion that the lesion of the intestine in typhoid 
fever is the pathological cause of the disease. The article has 
little or no value for Americans, for the simple reasons, that 
typhus fever, without lesion of the intestines, is a form of dis- 
ease rarely met with in this country, except amongst emigrants 
recently arrived from Europe; and that no clear and well-defined 
difference is recognized between this and the form of continued 
fever generally prevalent here. 

The Article in the Cyclopedia of Practical Medicine is by Dr. 
Tweedie. He recognizes no essential difference between typhoid 
fever, and typhus. The paper in the Cyclopedia, on Epidemic 
Gastric Fever, by John Cheyne, is to us much more interesting 
and valuable. The disease described under this name is very 
clearly true typhoid fever. 

The more or less systematic treatises of Dr. Armstrong, South- 
wood Smith, and Tweedie, have already been sufficiently referred 
to. Many of the most valuable publications upon typhus fever 
are to be found in the British Hospital Reports, in the Transac- 
tions of Medical Societies, and in the pages of Medical Journals. 

The Transactions of the American Medical Association. Vol. 
I. 1848. Report of the Committee on Practical Medicine. The 
author of this well-written Report is my friend and colleague, 
in the New York College of Physicians and Surgeons, Dr. Smith. 
More than half of it is devoted to an elaborate and methodical 
examination of the question of the identity or the non-identity of 
typhus and typhoid fever. Dr. Smith argues with earnestness 
and ability the New York doctrine. 

" Report on the Epidemic Fever in Ireland,'" during the 
years 1847 and 1848. Dublin Quarterly Journal. Vol. VII. 
and VIII. 

This elaborate Report occupies nearly three hundred pages of 
the Dublin. Journal. Its general plan and purpose are very 
similar to those of the great work of Barker and Cheyne. The 
histories of the epidemic contained in it are so general in their 



344 TYPHUS FEVER. 

terms and character as to be of little service to me in this work. 
It contains abundant evidence, I think, that the epidemic of 
1847-8 was made up of seyeral forms of fever. In relation to 
this matter, I make the following extract from the report of 
Dr. Seaton Reid, of Belfast. 

" I have stated above that the epidemic here was constituted 
by the prevalence of several diseases, and I now add that in the 
fever portion of these we had prevailing several separate and 
distinct species of fever. Twelve years' connection with fever 
hospitals has convinced me that a very serious error has been 
committed by almost all the most recent writers of monographs 
on fever, by their denying the existence, both in this country 
and in England, of more than one species of that disease. This 
error exists in the works of Drs. South wood Smithy M'Cormac, 
Ormerod, and others, and will be found pervading almost all the 
communications in Barker and Cheyne's report of the epidemic 
f 1816—1818. 

" The consequence of this error has been, that we do not possess 
that amount of precise information regarding the history, the 
symptoms, the pathology, and the relative mortality of our 
several species of fever, as their frequent prevalence in this 
country would lead one to expect. In this respect the American 
physicians are in advance of us, for Drs. Bartlett, Jackson, and 
others, have not only recognized and described the several species 
of fever peculiar to America, but have also pointed out the dif- 
ference existing between our maculated typhus, carried into their 
cities by our emigrants, and their own typhoid fever — the species 
of fever' so minutely described by Louis in Paris, and which has 
been so often confounded with our maculated typhus." 1 

1 Dub. Med. Journ., vol. viii. 



PART THIRD- 



THE 

HISTORY, DIAGNOSIS, AND TREATMENT 



OF 



PERIODICAL FEVEE. 



INTERMITTENT; BILIOUS REMITTENT; CONGESTIVE. 



PART III. 
PERIODICAL FEVER. 

INTERMITTENT; BILIOUS REMITTENT; CONGESTIVE. 



CHAPTER I. 

PRELIMINARY MATTERS. 

ARTICLE I. 

INTRODUCTORY. 

Before commencing the formal description of the disease 
which is to constitute the subject of this Third Part of my book, 
it is necessary to say a few words about the names which I have 
placed at its head. The disease which I am here to describe 
exhibits itself under several forms, so considerably different from 
each other as to have received different appellations. Still, the 
disease under all its forms, in all its varieties and modifications, 
is a single, individual disease; as clearly so as typhoid or typhus 
fever is. It becomes necessary, then, that this disease should 
have its distinctive appellation — a name by which it may be 
designated and known. I have accordingly adopted the term — 
not a new one — Periodical Fever, as more descriptive and appro- 
priate than any other, and entirely unexceptionable. Periodical 
Fever is the integral, individual, nosological disease; Intermit- 
tent Fever; Bilious Remittent Fever ; and Pernicious Intermit- 
tent or Congestive Fever, are the three principal forms, or vari- 
eties, in which the disease shows itself. 

I have felt a little embarrassment in deciding upon the best 
and most suitable method of procedure, in describing the disease 
thus designated and divided. The three leading varieties have 



348 PERIODICAL FEVER. 

many elements in common ; they are branches springing from 
the same root; but notwithstanding this, they differ in some 
respects so widely from each other that they have often been 
regarded as specifically distinct and separate diseases, and in 
order to get any clear and adequate conception of them they 
must be separately and individually described. If this descrip- 
tion is extended, in detail, to their entire natural history, it will 
lead us into a great deal of tedious and unnecessary repetition ; 
and it would be very difficult to convey to the reader anything 
like a complete and satisfactory idea of them, by attempting to 
carry along together the description of the several varieties — 
endeavoring to put into the same portrait various and differing 
expressions. Amidst these difficulties, the best course seems to 
me to be this — to give, in the first place, a full and detailed 
description of one of the forms of periodical fever, comprising in 
this description all the phenomena and relations that are common 
to all the forms; and then to point out only the peculiarities and 
characteristics of the remaining varieties. Which of the three 
principal forms of periodical fever we choose for this more 
elaborate and formal description, is not altogether a matter of 
indifference ; and it would probably strike one, at first sight, that 
this choice would naturally fall upon intermittent fever, as the 
simplest and least complicated of these forms — as the* type- 
variety, in some degree, of the disease — and, for this reason, 
better adapted than the others to exhibit its characteristic features 
and its true nature. I am satisfied, however, that this view is not 
the correct one ; and that our purpose will be much more suc- 
cessfully accomplished by giving a full description, in the first 
place, of the bilious remittent variety; filling up and completing 
the picture, subsequently, by introducing the lights and the 
shades that mark the other forms. The principal reason for 
making choice of this variety, for this purpose, consists in the 
fact that it embraces a larger number of the phenomena and 
relations which enter into the composition of the entire disease 
than either of the other varieties. 

The sources of my materials for the history of periodical fever 
will be indicated as I go along. I may mention here, however, 
that the most valuable of these materials are derived from French 
and American observers. The British Islands are not, to any 
great extent, the seat of periodical fever; and although some 



PRELIMINARY MATTERS. 349 

British writers have left us excellent general descriptions of the 
disease, as it shows itself in the southern and tropical colonies of 
the British empire, these descriptions are less elaborate and com- 
plete than those of some of the more recent French and Ameri- 
can physicians. The earlier classic authorities upon this subject 
were the great Italian writers — Torti, Baglivi, Lancisi, and Ra- 
mazzini. But their descriptions are generally inaccessible here, 
and they are of course but little known ; it should be said further, 
that they are quite deficient in pathological details. I do not 
know that the modern Italians have done anything in this depart- 
ment in any way worthy their illustrious predecessors. Italian 
medicine, like Italian art, Italian science, Italian poetry, and 
Italian character, has fallen from its high estate, and partakes in 
the general lethargy that broods over that beautiful land. 

ARTICLE II. 

NAMES OF THE DISEASE. 

There are not many diseases with so few synonymes as this 
variety of periodical fever, if we except those names that have 
been given to it on account of its geographical relations. Thus, 
in common with the other grave forms of periodical fever, it has 
been called Walelieren fever, Hungarian fever, African fever, 
and so on; in India, it is frequently called jungle or hill fever. 
It should be added that it has frequently been confounded, espe- 
cially by British writers, with the yellow fever, and designated 
by some of the many names which have been applied to the latter 
disease. Its most common names are these — Remittent Fever; 
Bilious Fever ; and Bilious Remittent Fever. 



350 



CHAPTER II. 

SYMPTOMS. 

ARTICLE I. 

MODE OF ACCESS. 

The onset of remittent fever is almost always abrupt, formal, 
and well marked. This onset, according to many observers, is 
not usually preceded by any precursory symptoms ; according to 
others it is, if not generally, at least in many instances, ushered 
in by such symptoms. Dr. William Currie says that the fever 
makes its attack, after the existence for a day or two and some- 
times much longer of a disagreeable sense of languor and de- 
bility. 1 Dr. Boling, in his excellent paper on the remittent fever 
of Southern Alabama, says that, although the attack sometimes 
takes place without any premonitory symptoms whatever, it is 
most frequently preceded for a day or two by slight headache, 
want of appetite, bitter taste in the mouth in the morning, pains 
in the joints, and a general feeling of discomfort and uneasiness. 2 
Dr. Dunlavy, in a paper on the bilious fever as it prevailed in 
the town of Hamilton and in its vicinity, in Ohio, during the 
summer and autumn of 1824, remarks that, in some cases, 
patients complained of pain in the head, sickness of the stomach, 
occasional vomiting, and bitter taste, for several days previous to 
the occurrence of a chill. If examined at this time, their tongues 
were found more or less furred, with some frequency of the pulse. 
During the prevalence of the disease, he met with many persons 
having a furred tongue, who were not aware of any indisposition ; 
and he adds that this symptom foreboded an attack of fever, 
which very certainly sooner or later occurred, unless prevented 

1 Obs. on Causes and Cure of Remitting Fevers, p. 45. 

2 Am. Journ. of Med. Sci., April, 1846. 



SYMPTOMS. — CHILLS. 351 

by a timely use of evacuant medicines. 1 Senac says: " The 
access of the chilly fit is usually preceded by various pheno- 
mena. These are, a general lassitude and heaviness, a sense of 
anxiety, a yawning and stretching, a paleness, and sometimes a 
disposition to sleep." 2 



ARTICLE II. 

FEBRILE SYMPTOMS. 

Sec. I. — Chills. The formal commencement of the disease is 
nearly always marked by a distinct rigor or chill. This varies 
in severity and duration in different cases : sometimes it is slight 
and transient, at others it is extremely severe, and prolonged for 
two or three hours. Senac says : " The chilly fit puts on a variety 
of forms ; sometimes, for instance, beginning at the feet, at other 
times about the scapulae, and again in the back, it runs through 
the whole body, in a manner resembling small streams of water 
poured irregularly in every direction." 3 According to Dr. Boling, 
the initiatory chill is generally slight; sometimes it is a well- 
marked ague, while at others it consists merely in a sensation of 
coldness, felt especially when the patient turns in bed, or in any 
way disturbs his covering. 4 In some cases, there is only a single 
chill ; in others, the chill is repeated, usually with diminishing 
severity, once, twice, three times or more in the course of the 
disease. Dr. Boling says : " Where the attack is purely remit- 
tent from the beginning, a second well-marked ague hardly ever 
occurs ; though in all cases whether the first exacerbation was 
ushered in by an ague, or merely by slight rigors, a recurrence of 
the latter in a very slight degree frequently precedes the second 
and third, and occasionally, even the fourth and fifth exacer- 
bations. Where the fever is of the double tertian type, the first 
and third perhaps the fifth exacerbation may be ushered in by 
tolerably distinct agues, while the second and fourth may be pre- 
ceded by but the very slightest sensation of coldness if any." 5 
Dr. Stewardson says : " The recurrence of the chill was subject 
to great diversity : either there were none after the first, or they 

1 West. Med. and Phys. Journ., vol. i. p. 142. 

2 Caldwell's Senac, p. 24. 3 Caldwell's Senac, p. 24. 
4 Am. Journ. Med. Sci., April, 1846. * Ibid., April, 1846. 



352 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

recurred at intervals, most commonly of twenty-four or forty-eight 
hours, for the first few days, and then disappeared altogether, or 
again reappeared towards the conclusion, or during convalescence; 
or, finally, showed themselves at various intervals throughout the 
whole course of the disease. 1 Dr. William Currie says : "After 
the second paroxysm, and sometimes after the first, the fever is 
seldom preceded by a cold stage." 2 

Sec. II. — Remissions, or Type. This disease is so uniformly 
and so strongly marked by a repetition or recurrence of certain 
symptoms and states of the system, more or less regularly periodi- 
cal, that one of its qualifying terms has been derived from this 
circumstance. At certain periods of the clay, there is an augmen- 
tation in the intensity of all or nearly all the symptoms of the 
disease, sometimes preceded and at other times not preceded by 
the chill. This increase of the severity of the symptoms con- 
stitutes what is called the paroxysm of the fever, or its exacerba- 
tion. Following this period, and between it and the next, there 
is a general diminution in the activity of the morbid processes and 
their manifestations, constituting what is called the period of 
remission. When these paroxysms and remissions occur, each 
once in twenty-four hours, the type of the fever is said to be quo- 
tidian; when they occur once in forty-eight hours, the type is 
called tertian; when once in seventy-two hours, it is called 
quartan, and so on. The most common type is the quotidian, or 
more strictly, perhaps, what has been called the double tertian. 
In this form, there are a paroxysm and a remission during each 
twenty-four hours ; but the paroxysm of one day differs in severity 
or in some circumstances from that of the preceding and of the 
following day, and agrees with that of the third day. The parox- 
ysms of the alternate days correspond to each other. Besides 
these, the most common, there are occasionally other varieties of 
type. Sometimes, for instance, in the tertian form, there are three 
paroxysms and three remissions, instead of one or two during 
each period. This is the semi-tertian of some writers ; it is the 
triple tertian of Cleghorn. The other varieties it is hardly neces- 
sary to enumerate. The term true has been applied to those 

1 Am. Journ. Med. Sci., April, 1842. 2 Currie on Rem. Fevers, p. 46. 



SYMPTOMS. — TYPE. 353 

forms of the disease in which the duration of the paroxysm does 
not exceed twelve hours ; when this is considerably protracted, 
the fever is called spurious; and subiatrant, when the paroxysms 
nearly run into each other. 

It is alleged by most observers, that the commencement of the 
paroxysm occurs much more frequently at certain periods of the 
day than at others. Dr. William Currie, for instance, says the 
first attack of the fever is usually between eight and eleven 
o'clock in the forenoon. 1 Dr. Cleghorn, in his admirable little 
Treatise on the Diseases of Minorca, makes the following remarks 
upon this point in the history of remittent fevers. " Some 
double tertians begin in this manner : on the evening of Monday, 
for example, a slight fit comes on, and goes off early next morn- 
ing; but on Tuesday, towards the middle of the day, a more 
severe paroxysm begins, and continues till night. Then there 
is an interval to Wednesday evening, when a slight fit commences 
a new period of the fever, which proceeds in the same manner as 
the first. In most double tertians, the patient has a fit every 
day of the disease ; the severe one commonly appearing at noon 
on the odd days, the slight one towards evening, on the even 
days." 2 Dr. James C. Finley, in a paper on the Autumnal 
Fever of Georgia, says, that " the type is uniformly double ter- 
tian, the paroxysms recurring with the greatest regularity; one 
paroxysm commencing in the morning, and manifesting a dispo- 
sition to terminate in the evening of the same day; the other 
commencing on the afternoon of the following day, and continu- 
ing through the greater part of the night." Dr. Finley says, 
further, that " there is a very marked difference in the character 
of these two paroxysms ; that which commences in the morning 
being always more violent and dangerous than that which comes 
on in the afternoon of the next day." 3 Dr. Boling thinks that 
the period of attack will depend very much upon the time of the 
patient's exposure to the exciting cause, but he says distinctly 
that, in fevers of the double tertian type, the exacerbations will, 
in a large majority of cases, be found to occur alternately in the 
fore and after part of the day. 4 It has often been alleged 
that the usual period of access varied with the different types of 

1 Currie on Rem. Fever, p. 45. 2 Cleghorn on Dis. of Minorca, p. 90. 

3 West. Journ. Med. and Phys. Sci., vol. iii. p. 175. 
* Amer. Journ. Med. Sci., April, 1846. 

23 



354 



PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 



the disease, occurring early in the morning in the quotidian type, 
between ten o'clock and noon in the tertian, and between three 
and five o'clock in the afternoon in the quartan. In relation to 
this subject, M. Maillot has published the following curious and 
interesting table. I omit his distribution of the cases according 
to the month in which they occurred. It will be noticed that, in 
the two principal types, two-thirds of the cases have their access 
between midnight and noon; that the maximum hour is ten 
o'clock A. M., and the minimum period from nine P. M. to mid- 
night. M. Maillot did not find that the period of access was in 
any appreciable degree influenced by the season, or the tempera- 
ture of the weather. 

Table showing the hours of access in periodical fever. 

QUOTIDIAN TYPE. 

From Midnight to Noon. 

Hour, 1234567 8 9 10 11 12 Total. 

No. of cases, 12 15 17 18 31 51 82 118 163 239 137 206 1089 

From Noon to Midnight. 

12 3 4 5 6 7 8 9 10 11 12 Total. 
70 113 63 58 54 47 19 22 8 21 10 8 493 



TERTIAN TYPE. 

From Midnight to Noon. 

Hour, 1234567 8 

No. of cases, 12 5 12 30 22 38 68 63 

From Noon to Midnight. 

1234567 8 
33 39 23 27 11 11 9 10 



9 10 11 12 Total. 
86 87 72 55 550 



10 11 
8 4 



12 Total. 
3 180 



Hour, 

No. of cases, 



QUARTAN TYPE. 

From Midnight to Noon. 

4 5 6 7 8 & 10 

1 2 « " " " « 

From Noon to Midnight. 

4 5 6 7 8 9 10 11 
12 11 " " " 1 



11 

3 



12 Total. 
5 13 



12 Total. 
« 13 



No distinction is made in the above table between the different 
forms of periodical fever, and the double tertian is not recognized 
as a distinct type. 1 



Traite des Fievres Intermittentes. Par F. C. Maillot, p. 414. 



SYMPTOMS. — SKIN. 355 

In regard to the relative frequency of the leading types, I find 
the following positive and valuable statement in the excellent 
work of Maillot. His remarks apply, without discrimination, to 
the three great forms of periodical fever, intermittent, remittent, 
and congestive. At Bona, in Africa, of two thousand three 
hundred and thirty-eight cases, fifteen hundred and eighty-two 
were quotidian, seven hundred and thirty were tertian, and twenty- 
six were quartan in their type ; at Algiers, of seven hundred 
and seventy-six cases, five hundred and ninety-nine were quoti- 
dian, one hundred and seventy-one tertian, and six quartan. In 
France, according to M. Nepple, of three hundred and eighty- 
six cases, one hundred and ninety-eight were quotidian, one 
hundred and fifteen tertian, and fifty-nine, quartan. Thus, of 
three thousand five hundred and eighty-six cases, two thousand 
three hundred and seventy-nine were quotidian, eleven hundred 
and sixteen were tertian, and ninety-one were quartan in their 
type. M. Maillot makes no distinction between the simple 
quotidian and the double tertian type. 1 

It would seem that there is sometimes a tendency to a weekly 
revolution in the phenomena of this disease. Dr. Forry says : 
" That intermittent fever has a tendency to a septenary revolu- 
tion, is a fact that was frequently verified in Florida, under the 
writer's observation ; and that too in a manner so unequivocal, 
that it attracted the notice of the common soldier. At these 
septenary periods, either after the seventh, fourteenth, or twenty- 
first paroxysm, the disease has a disposition to terminate spon- 
taneously." 3 

Sec. III. — State of Surface. The condition of the skin, like 
most of the other symptomatic phenomena of bilious fever, varies 
very much with the several stages and periods of the disease. 
Cleghorn says, that the cold fit is generally followed by an intense 
heat over the whole body, which raises the mercury in the ther- 
mometer to the 103d or the 104th degree. 3 According to Dr. 
Stewardson, the heat of the skin, during the exacerbations, though 
often great, is not often pungent. 4 Dr. Boling seems to have 
studied this matter more thoroughly and minutely than any other 

1 Traite des Fievres Intermittentes. Par F. C. Maillot, p. 9. 

2 Amer. Journ. Med. Sci., Oct. 1841. 

3 Dis. of Minorca, p. 94. « Amer. Journ. Med. Sci., April, 1842. 



356 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

observer, and I accordingly avail myself of his full description. 
" In the forming stage of the first exacerbation, the extremities 
generally feel cool or cold to another person, though this is not 
always the case, even when the complaints of suffering from cold 
are loudest on the part of the patient. The temperature of the 
chest and abdomen, even at this time will generally be found 
somewhat above the healthy standard, and that of the head con- 
siderably so. Soon, however, the general temperature increases, 
and the whole surface becomes hot, and a vivid flush makes its 
appearance, not only on the face, but occasionally over the whole 
body, in patients at all plethoric, or of a sanguine temperament. 
This continues for a longer or shorter period, dependent in a 
great measure on the type the fever is about to assume ; for it 
will be shorter in the paroxysm of a quotidian than of a tertian, 
when the heat and redness of the surface decline, and a perspi- 
ration appears, in the form at first of the slightest moisture be- 
tween the under jaw and neck, gradually becoming general and 
free. In the succeeding paroxysms, the heat of the body is still 
about the same ; but if the case be at all protracted, there is after 
a certain period a tendency to coolness in the extremities, even 
during the height of the exacerbations ; but unlike the coolness 
attending the early rigors, the patient is unaware of it, and is 
much distressed with a sensation of burning heat. This coolness 
of the extremities gradually increases with each succeeding exa- 
cerbation, after it has once appeared, and in cases far advanced 
towards a fatal termination frequently extends nearly to the 
shoulders and groins, the surface of the abdomen and chest 
being most intensely hot at the same time. The perspiration 
attending the remissions becomes less and less in each, and in 
the advanced stages of an aggravated case is replaced by a 
clammy exudation from the cold extremities, while the body is 
dry and parched. The vivid flush of the surface is much less 
apparent with each succeeding exacerbation, and in its place a 
very slight shade of a purple or livid tint makes its appearance 
— more obvious in the face than elsewhere. Frequently, how- 
ever, the skin becomes yellow : the shade, scarcely perceptible 
at first, gradually deepening over the whole body, but not 
commencing and proceeding from any particular point, as is said 
to be the case by Lempriere, Bancroft, Mosely, and others, in the 
yellow fever. It is, however, for a very obvious reason, most fre- 



SYMPTOMS. — HEART AND PULSE. 357 

quently first noticed in the conjunctiva. Petechia and vibices are 
never seen, though sudamina are occasionally observed in pro- 
tracted cases. They generally appear only about the neck and 
breast, and are much more common with children than with 
adults." 1 It should be mentioned that DrNBoling's remarks 
have reference especially to the severer forms of the dis.eas^e. 

Sec. IV. — Heart and Pulse. * , The pulse is more or less accele- 
rated during the febrile paroxysms, rising frequently to 120 or 
130 in the minute, and falling nearly to its natural standard in the 
intervals. Of eleven cases treated by Dr. Gerhard, at the Penn- 
sylvania Hospital, in 1834, and all terminating in recovery, the 
pulse was over 100 in only two. It is very rarely that it has the 
hard tense feel of the open inflammatory pulse. Sometimes it is 
moderately hard and strong, or jerky; but more commonly it is 
rather soft and feeble. Towards the close of fatal cases, the 
pulse usually becomes excessively rapid, " becoming smaller and 
thready, and at length imperceptible." 2 Dr. Boling remarks, that 
the action of the heart is laboring and strong, its sounds louder 
than natural, and its impulse more forcible. 

ARTICLE III. 

THORACIC SYMPTOMS. 

Very few writers upon remittent fever make any formal mention 
of symptoms connected with the respiratory organs ; and it seems 
quite certain that thoracic complications are rare and accidental. 
Bronchitis, sometimes with mucous rattle, but oftener without it, 
occurred in twelve of Dr. Swett's thirty-four cases ; and he thinks 
that pneumonia was the immediate cause of death in two in- 
stances. Dr. Stewardson speaks of the general infrequency of 
this class of symptoms; and Dr. Boling merely mentions the 
moderate acceleration of the breathing usually accompanying 
febrile excitement. 

1 Amer. Journ. Med. Sci., April, 1846. 

2 Dr. Swett, in his account of thirty-four cases treated at the New York Hos- 
pital, in 1844, says that, during the paroxysm, the pulse usually ranged from 106 
to 112, falling in the intervals to 96 or 100. 



358 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

ARTICLE IV. 

CEREBRO-SPINAL, OR NERVOUS SYMPTOMS. 

Sec. I. — Headache; Pains in the Bach and Limbs. Pain in 
the head, back, and limbs is one of the most constant, and in 
many cases one of the most distressing accompaniments of this 
disease. Cleghorn says he has sometimes known this pain so 
intolerable, and accompanied with such inexpressible anxiety, 
that persons of the soundest judgment and morality have been 
tempted to destroy themselves to get rid of it. 1 Dr. Stewardson 
found headache present in all but one of sixteen cases^ terminating 
in recovery. It generally commenced on the first day of the 
fever, was most severe during the exacerbations, and commonly 
declined after the middle period of the disease, at least during 
those hours of the day when the patients were visited. 2 Dr. Boling 
gives the following account of this symptom as it shows itself in 
severe cases. " As the febrile excitement is developed in the first 
exacerbation, pain in the head becomes violent and distressing, 
and is of a throbbing character. It is generally in the forehead, 
just above the frontal sinuses, but is also occasionally felt in the 
occipital region. During the earlier remissions it either abates 
or entirely subsides, but later is very distressing during the remis- 
sions. At this period, too, it loses its throbbing, pulsating cha- 
racter, and is fixed and steady." 3 

Sec. II. — Mind. Decided delirium is not a common symptom, 
at least in mild cases, and in those of moderate severity. There 
was slight delirium in only one case of eleven, terminating in 
recovery, at the Pennsylvania Hospital, in 1834. Of fifteen 
cases, also terminating favorably, in the same institution, ob- 
served by Dr. Stewardson, delirium was noticed in only two. In 
one it was slight ; in the other violent, and in both confined to 
the exacerbations. Of Dr. Swett's thirty-four cases, at the New 
York Hospital, there was delirium in five. Dr. Boling's account 
of this symptom, as of many of the others, is more particular and 
minute. It is important to remember that he is speaking only of 

1 Dis. of Minorca, p. 132. 2 Amer. Journ. Med. ScL, April, 1842. 

3 Ibid., April, 1846. 



SYMPTOMS. — MIND. 359 

grave cases, although always of the simple and not the malignant 
or congestive form of the disease. " Where the febrile excitement 
runs high," he says, "slight temporary delirium occurs, even 
during the first exacerbation. It is most frequently associated 
with a drowsy stupor, during the partial waking from which it is 
manifested, and passes away as soon as the patient is sufficiently 
roused to bestow his attention. This delirium, like the dry tongue 
in the first exacerbation, may be present in cases of but moderate 
severity, and under the use of a gentle cathartic, a small bleeding, 
or the spontaneous evacuation of the stomach, disappear, not to 
return again in the succeeding exacerbations, although the vio- 
lence of the disease may not be subdued ; and, indeed, in cases 
in which the symptoms generally are on the increase as regards 
severity, it may remain absent during several exacerbations, and 
then again appear, or may not return again at all, should the 
patient recover; or, should he die, but in the last exacerbation. 
With the exception of this temporary delirium just spoken of, a 
patient is apt to pass through several exacerbations without any 
intellectual aberration. It generally occurs earlier in sanguine, 
plethoric subjects, and in such is less indicative of danger. Once 
fairly established, with the exceptions above noted, like all the 
other phenomena of the disease, while the other symptoms are on 
the increase, this one is also progressive, and becomes worse and 
worse with every exacerbation. During the remissions, at least 
the earlier ones, the delirium disappears, and even in the later 
ones generally abates considerably in violence, though but shortly 
before a fatal termination. An amendment once commenced, in 
a case where the delirium disappears during the remission, this 
symptom scarcely ever returns, however slow the progress of the 
cure ; but where the delirium remains during the remission, it 
may continue even after a decided amendment has taken place, 
abating more or less every day till its complete disappearance, 
which always takes place during the hour of remission. The 
delirium is scarcely ever so violent, except in a few malignant 
cases that run through their course very rapidly, as to require any 
restraint of the patient. In a very few protracted cases only does 
it assume that character called low and muttering, and is seldom 
if ever attended with picking the bedclothes, or subsultus ten- 
dinum, though occasionally the hands are extended in sleep, as if 



360 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

reaching for some imaginary subject of a troubled dream." 1 Som- 
nolence, dulness, or stupor, is an occasional but not very constant 
or striking symptom. 

Sec. III. — Senses, and Physiognomy. Dizziness and ringing 
in the ears are present in a certain number of cases, but they are 
far from being common. Deafness is hardly ever noticed. Dr. 
Boling says: "The expression of the eye has nothing peculiar in 
it in the earlier exacerbations. Where the febrile excitement 
runs high, it is, perhaps, bright and sparkling, the conjunctiva 
retaining its pearly whiteness, and this sometimes continues to 
the last paroxysm; the patient's countenance wearing now an 
expression of indescribable anxiety. At other times it is suf- 
fused, and of a reddish muddy tinge ; its motions are slow and 
languid ; and, in such instances, the countenance wears rather an 
expression of dull indifference." 2 

Sec. IV. — Muscular Strength. Prostration of muscular 
strength, and a sense of debility, are early and almost invariable 
attendants of remittent fever. But, according to Dr. Boling, 
this extreme degree of feebleness is sometimes more apparent 
than real. He says: " The sensation of debility is extreme, and 
is frequently as much complained of in the first or second ex- 
acerbations as later in the disease, when the actual debility is 
much greater. At a time when a patient will make complaints 
of the greatest debility, let it become necessary for him to get 
up, or assist himself in any way, and he will do so without any 
call for aid; or if he does demand it, will show himself at the 
same time capable of considerable muscular exertion. It is only 
in very protracted cases — and few such occur in this part of the 
country — that the patient requires much assistance in performing 
any necessary movements, provided he is sufficiently sensible to 
be aware of what is necessary." 3 Twitching of the tendons, and 
hiccough, are present in a small proportion of cases. 

1 Amer. Journ. Med. Sci., April, 1846. 

2 Ibid., April, 1846. 

3 Ibid., April, 1846. 



SYMPTOMS. — TONGUE AND MOUTH. 361 

ARTICLE V. 

DIGESTIVE AND ABDOMINAL SYMPTOMS. 

Sec. I. — Tongue and Mouth. The tongue is generally more 
or less thickly covered with a yellowish, or dirty white fur — the 
color being probably occasioned in many cases by the fluids 
ejected from the stomach. The edges of the tongue are often 
somewhat redder than natural. During the early periods of the 
disease the tongue usually retains its moisture ; but in grave cases, 
especially, and after the third or fourth paroxysm, it frequently 
becomes parched and dry, dark brown, or nearly black on the 
dorsum, more intensely red on its edges, and sharpened at its 
point. Dr. Swett found the tongue usually coated, first with a 
thin white, and at length with a more thick and dirty coat, but 
remaining moist to the end of the disease, in at least two-thirds 
of the cases ; it was noted as becoming dry in only twelve of 
thirty-four cases. 1 These and other morbid states of the organ 
are much more strongly marked during the paroxysms than in 
the intervals, at which time the tongue often returns nearly to its 
natural condition. In eleven of Dr. Stewardson's cases which 
recovered, where this point was noticed, the tongue began to clean 
on or before the twelfth day in eight, and from the thirteenth to 
the twentieth in the remaining three. 

There is more or less dryness of the mouth during the febrile 
paroxysms. "Late in the disease," says Dr. Boling, "when the 
case is of so aggravated a character that a few shades further 
put it beyond hope, the whole interior of the mouth becomes as 
it were almost completely dry, and the mucus, inspissated, dry, 
and black, is collected on the lips and between the teeth. The 
patient, during the first two or three paroxysms, frequently com- 
plains of a bitter taste in the mouth; but after this, with the 
exception of the impression made by matters vomited up, and the 
taste left by medicine, nothing peculiar in this respect is observed, 
till the commencement of convalescence, when a disagreeable 
bitter taste is again complained of for a few days." 2 Dr. 
Stewardson says sordes about the teeth either did not exist or 
were so slight as not to be noticed. 

1 Am. Journ. Med. Sci., Jan. 1835. 2 Ibid., April, 1846. 



362 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

Sec. II. — Appetite and Thirst. The testimony of observers 
is very uniform in regard to the entire absence of appetite for 
food. Dr. Boling says : " From the commencement of the 
attack, during nearly the whole period of the disease, the disgust 
for food is almost insurmountable. It is only during one or two 
of the earlier and more complete remissions that a patient can be 
induced to swallow any kind of nourishment, and that only at the 
solicitation of friends, and not from any desire of his own. 
Towards the close of a case that is taking a favorable turn, and 
before the establishment of complete convalescence, he will swal- 
low a few spoonfuls of light broth, or something of that charac- 
ter ; and even then not to gratify any desire of his appetite, but 
from a persuasion that nourishment is necessary for him in his 
weak state. When convalescence is completely established, the 
appetite is generally craving, and the strength is rapidly restored. 
In the case of negroes, the disgust for food is a much less promi- 
nent symptom. 1 

The thirst, the desire being for cold drinks, is most excessive 
from the very first paroxysm, and this is almost the only symptom 
of the disease which does not increase with the repeating exacer- 
bations, so long as the disease may be considered unchecked. 
But although the thirst in the first exacerbation is, as a general 
rule, so great as to leave no room for it to increase, it is not so 
with the remissions. During the first remission the thirst abates 
somewhat, but this abatement is less and less with each one that 
succeeds, and after a while, even during the period of remission, 
the thirst is most excessive, and large draughts will be rapidly 
and in quick succession swallowed, although with the .confirmed 
assurance that in a few minutes they must be returned. Pure 
cold water is the drink most generally preferred, and if any addi- 
tion is at all desired, it is always something sour, such as vinegar, 
tartaric acid, or lemon-juice. 2 Dr. Baldwin, in his account of the 
bilious remittent fever which prevailed in Burke County, Georgia, 
in 1831, says that a bitter taste in the mouth, and an intolerable 
thirst were universally present. 3 Bailly says : " One must be 

1 This peculiarity in the case of negroes was noticed by Dr. Gerhard in the 
epidemic typhus of Philadelphia, in 1836, and has already been spoken of in this 
work. 

2 Amer. Journ. Med. Sci., 1846. 3 Ibid., Feb. 1832. 



SYMPTOMS. — VOMITING. — EPIGASTRIUM. — ABDOMEN. 363 

sick at Rome, in order to know the happiness of drinking cold 
water." 1 

Sec. III. — Nausea and Vomiting. These symptoms are 
amongst the most constant phenomena of the disease. Vomiting 
very often accompanies the first rigor ; and in most cases is more 
or less frequently repeated, especially in the paroxysms, during 
the whole course of the disease. The fluids ejected from the 
stomach are usually of a greenish or yellowish tinge, varying in 
shade and intensity in different cases. Dr. Boling says that, in 
grave cases, and in the advanced periods of the disease, although 
the efforts to vomit become more incessant, the matter vomited 
diminishes in quantity, so that frequently, in hours of straining 
and retching, nothing is thrown up but the drinks which had 
recently been swallowed. 

Sec. IV. — Epigastrium and Abdomen. Another symptom 
belonging to this strongly marked group, and almost invariably 
present, is pain or tenderness of the epigastrium, increased by 
pressure. There is also some degree of fulness, or a sense of 
fulness, weight, tension, and oppression, extending across the 
hypochondria, especially on the left side, in the region of the 
spleen. This feeling is often quite distressing, and adds much to 
the discomfort of the patient. The epigastric uneasiness and 
oppression are often relieved, temporarily at least, according to 
Dr. Boling, by the act of vomiting. True tympanitic distension 
of the abdomen is of rare occurence. 2 Enlargement of the spleen 

1 Traite des Fievres Intermittentes, p. 137. 

2 Dr. Doling has an observation somewhat opposed to the statement -which I 
have considered myself justified in making in relation to this symptom. " Some- 
times," he says, "in cases of a very violent character, this tympanitic distension 
supervenes early in the disease under the action of a few small doses of purga- 
tive medicine, and accompanies almost always a spontaneous diarrhoea, which, in a 
few cases, makes its appearance early.'" In the absence of any distinct and con- 
clusive information upon this point, one can hardly avoid the suspicion that the 
cases thus marked by tympanites and spontaneous diarrhoea were cases of typhoid 
fever. A previous remark by Dr. Boling justifies, I think, the suspicion which I 
have ventured to suggest. Towards the close of protracted cases, he says, there is 
sometimes an obscure sensation of pain behceen the umbilicus and the right iliac fossa. 
At any rate, and be this as it may, the general absence of this symptom is expressly 
admitted by Dr. Boling, as well as by other observers. Dr. Gerhard found it in 
only two of eleven cases at the Pennsylvania Hospital. Dr. Stewardson says, in 
the history of his cases, that flatulent distension, except in a slight degree, was 
not noticed in a single instance ; and Dr. Swett says that tympanites, even in the 
cases where prostration was most marked, seldom or never existed. 



364 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

is rendered manifest by the increased and extended dulness on 
percussion over the region of this organ. 

Sec. V. — Bowels. The bowels are, to say the least, generally 
free from any considerable degree of irritation, so far as this is 
indicated by pain or diarrhoea. Of Dr. Gerhard's cases at the 
Pennsylvania Hospital, there was diarrhoea in only one in seven. 
Dr. Stewardson, in his- account of seventeen cases, which were 
treated at the same institution, in 1838, all terminating in reco- 
very, says: "The bowels were generally costive, the purgative 
medicines which were given both before and after admission rare- 
ly occasioning hyper catharsis. In a few instances,^ spontaneous 
purging was present near the commencement of the disease, and 
continued for a few days ; but subsequently the bowels were either 
regular or costive, unless when operated on by medicine.'' 1 Dr. 
Swett remarks that diarrhoea was absent in almost every case, 
that all his patients required purgatives at some period of the 
disease, and that they usually acted freely without leaving any 
symptoms of irritation behind them. Dr. Boling thinks that this 
disposition to sluggishness in the bowels has been over-stated, 
and that, although spontaneous purging may be rare, there is 
still a strong tendency to diarrhoea — a tendency rendering great 
caution necessary in the use of cathartics, especially after the 
first or second exacerbation. It is very probable that the irri- 
tability of the bowels may be greater during certain periods, and 
in certain localities, than in others ; and it is very important, 
furthermore, to remember that Dr. Boling expressly excludes 
from his description the entire class of mild or moderate cases. 

The character of the discharges from the bowels seems to vary 
very considerably in different seasons, ' and in different localities ; 
and not unfrequently, also, during the different periods or stages 
of the disease. The more general, and to a certain extent cha- 
racteristic appearance of the stools, is that which has been deno- 
minated bilious. These stools vary in color, from different shades 
of yellow and green, to olive, brown, and almost black. Some- 
times this bilious quality of the discharges is entirely wanting. 
In the fever of 1831, in Dallas County, Alabama, Dr. Heustis 
found, early in the season, the discharges from the bowels mostly 

1 Amer. Journ. Med. Sci., April, 1842. 



SYMPTOMS. — URINE. 365 

of a light clay-colored complexion, with very little of the black, 
green, or bilious discoloration so generally present. In a few cases 
that occurred after the commencement of cool weather, the stools 
were highly colored, of a dark green, olive, and almost black ; 
becoming in the progress of the complaint of a lighter hue, be- 
tween an olive and a brown, and of a gelatinous, sleek, and oily 
appearance, but not peculiarly offensive. 1 Dr. Swett says: "In 
many the secretion of bile, as marked by the stools, was much 
increased in quantity or altered in its color, so as to constitute 
one of the most striking symptoms of the disease. This was ob- 
served in fifteen or about one-half the cases; while it was also 
noticed in many, even of the worst cases, especially among those 
which were admitted early in the season, that no apparent devia- 
tion from the healthy standard took place." 2 Lumbrici frequent- 
ly accompany the discharges, especially amongst negroes and 
children. 3 

Sec. VI. — Urine. Observers are not agreed amongst them- 
selves in regard to the state of the urine. Cleghorn says: " The 
urine, whether made in the time of the paroxysm or interval, is 
always clear, frothy, and of a deep red color, without any sepa- 
ration." 4 Senac lays greater stress on the appearance of the urine, 
as characteristic of periodical fever. " Masked intermittents," 
he says, "may be no less certainly detected, as was formerly 
observed, by the color of the urine. In that disease the urine is 
very often lateritious during the remission, which is a sign almost 
infallible that the disease belongs to this family." 5 According to 
Dr. William Currie, the urine during the cold stage is pale, 
copious, and crude ; but as soon as the hot stage is established, 
and during its height, it becomes high-colored; while in the re- 
mission it is thick and cloudy, and sometimes deposits a brick- 
colored or brownish mucous sediment. 6 Dr. Stewardson says: 
" The urine, where noted, was mostly clear, sometimes straw- 
colored, at others highly colored, reddish, or of a more or less 
deep yellow, approaching to orange." 7 Dr. Swett found the 
urine generally natural in appearance, and without sediment 

1 Amer. Journ. Med. Sci., Feb. 1832. 2 Ibid., Jan. 1835. 

3 Boling on Rem. Fever. 4 Dis. of Minorca, p. 133. 

e Caldwell's Senac, p. 122. « Currie on Bil. Fev., p. 46. 
' Amer. Journ. Med. Sci., April, 1842. 



366 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

throughout the disease. 1 Dr. Boling, on the other hand, says: 
"The secretion of urine is scant and highly colored and muddy, 
during the exacerbation, from the coloring matter floating sus- 
pended in it ; and sometimes late in the disease is of a deep red- 
dish-brown, possessing apparently a degree of consistency greater 
than natural, and is passed with pain. In the remissions it is 
more copious and transparent, but throws down a muddy floc- 
culent deposit sometimes; at others a red, pulverulent matter." 2 

1 Am. Journ. of Med. Sci., Jan. 1845. 2 Ibid., April, 1846. 



367 



CHAPTER III. 

ANATOMICAL LESIONS. 

ARTICLE I. 

LESIONS OF THE THORACIC ORGANS. 

Sec. I. — Lungs. The substance of the lungs, and the mucous 
lining of the air-tubes, are the seat of no constant or important 
lesion. Congestion of the former, especially in their posterior 
portions, and more or less redness of the latter, are found in a 
certain proportion of instances. Two of Dr. Swett's cases were 
complicated with pneumonia. Bailly mentions the lungs in only 
a part of his cases, and in nearly every instance where he does 
so, calls them healthy. Maillot found the lungs as free from dis- 
ease as after death from any acute affection. 

Sec. II. — Heart ; Blood. The muscular tissue of the heart 
is frequently softened and flabby. Dr. Stewardson found this 
organ flabby in three of the six cases in which it was particularly 
examined, and combined with this flabbiness there was diminished 
consistence at least in two cases. In nine of Anderson and 
Frick's twelve cases, the heart was examined, and in all of them 
its muscular tissue was found to be more or less softened. Mail- 
lot found the heart in six cases pale and softened, once of a yel- 
lowish color and flabby, once flabby with dilatation of the left 
ventricle, and in four cases with hypertrophy of the walls of the 
left ventricle. 1 In another place, Maillot calls the paleness and 
flabbiness of the heart, mentioned above, " truly remarkable ." 2 
Dr. Swett does not seem to have noticed particularly this altera- 
tion. In the three cases of Dr. Stewardson, where the heart was 
softened, its inner membrane was of a reddish brown, deep red, 

1 Traite des Fievres Intermittentes, p. 286. 2 Ibid., p. 291. 



368 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

or violet color ; in Anderson and Frick's cases, this membrane is 
generally described as pale. In regard to the nature of the fore- 
going lesions, I can only repeat what has already been said upon 
the same subject in connection with typhoid and typhus fever. 

The state of the blood in remittent fever has not yet been made 
the subject of sufficiently extensive or accurate study to justify 
us in saying anything very positive about it. Dr. Swett does not 
notice the blood at all, except to say that in one case, examined 
in the heart, it was fluid. Bailly takes no special notice of it. 
Dr. Stewardson examined the blood contained in the cavities of 
the heart in five cases: in one, there were black coagula, mixed 
with red serum ; in the others, fibrinous coagula, soft in two, 
semi-transparent and greenish in another, and generally small. 
No large, firm, fibrinous coagulum was found in a single instance. 1 
The state of the blood in the heart is mentioned in only one of 
Anderson and Frick's cases; in this there were large fibrinous 
concretions. 



ARTICLE II. 

LESIONS OF THE CEREBRO-SPINAL APPARATUS. 

Sec. I. — Brain, and its Envelops. I do not think that the con- 
dition of the brain and its membranes, after death from remittent 
fever, has yet been satisfactorily determined. It was examined 
by Dr. Stewardson in five cases. "The sub-arachnoid effusion 
was either entirely wanting or moderate, except in one case where 
there was a considerable quantity of reddish serum. In the same 
case, the ventricles contained an ounce of bloody serum, whilst 
in two of the others they were empty, in a third nearly so, and 
in the fourth contained scarcely a drachm of fluid. In one, the 
walls of the ventricles were of a yellow color. The pia mater 
was deeply injected in one case, in which also there appeared to 
be a slight effusion of blood into the cells in a small circumscribed 
space; its veins much distended posteriorly in another. The 
cortical substance was of a deep shade in two cases, and in none 
is it mentioned as being paler than natural, or presenting other 
alteration. In two cases, the medullary substance was natural ; 

1 Amer. Journ. Med. Sci., April, 1841. 



LESIONS. — BRAIN. 369 

in a third, it felt pasty without giving the sensation of softness ; 
whilst in a fourth it was soft and pasty, being at the same time 
dry and of milk white color, with few bloody points. In a fifth 
its color was a dirty white, mixed with a fain treddish brown — 
its consistence natural, with the exception of a slight central soft- 
ening." 1 Dr. Swett describes the substance of the brain as 
natural in four of his five cases ; in the other, the central portion 
of the left side was somewhat softened. In two cases, there wai 
slight sub-arachnoid effusion. Neither Dr. Stewardson nor Dr. 
Swett seem disposed to regard these cerebral lesions as in any 
degree important, or peculiar to this disease ; — they look upon 
them as wholly accidental, or at least such as occur with the same 
frequency and to the same extent in other acute febrile affections. 
This conclusion may prove to be sound ; but I do not think that 
w T e are justified in adopting it without more extensive researches. 
In ten of the twelve cases reported by Anderson and Frick, the 
brain and its membranes were examined, and in all of them 
there was more or less alteration. In eight, the substance of the 
brain was more or less injected; in two, it was natural. In two 
cases, the pia mater was healthy ; in the others, it was injected, 
or its meshes infiltrated with serum, or both; in one case, there were 
three ounces of serum between the arachnoid and dura mater. 2 In 
their connection with this subject, I have examined and analyzed 
with some care the cases reported by Bailly. They occurred at 
Rome, during the summer of 1822. It is important to remark 
that they all belonged to the variety of pernicious intermittc/it*. 
as they are called ; in other words, they were cases of congestive 
fever, as were also many of those the lesions of which have al- 
ready been described. Most of them were of the comatose form ; 
four only belonging to the strongly marked cold or algid variety. 
In twenty-five or twenty-six cases, the prominent cerebral symp- 
toms during the paroxysms were stupor or coma — the latter often 
profound in all — in many, spasmodic contractions of the muscles 
of one or both arms ; and in some few, delirium. The cerebral 
symptoms were also present in the algid cases, but less constantly 
and less strongly marked. In seventeen of the thirty-one cases 
in which the brain was examined, there was extensive or general 
inflammatory injection of the arachnoid membrane. In many 

1 Amer. Journ. Med. Sci., April, 1841. 2 Ibid., April, 1846. 

24 



370 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

instances this injection is described as intense, universal, and 
fine, extending to the minutest capillaries, and resembling a 
beautiful anatomical preparation. In some cases it was rather 
more strongly marked on one side than on the other. In two 
cases the meshes of the membrane contained coagulated blood ; 
and in two or three there was an effusion of fibrine. In the re- 
maining fourteen cases the membrane is described as moderately 
or slightly injected ; in only three or four was it natural. Another 
alteration consisted in a dark reddish-brown color of the cortical 
substance of the brain. This was present and strongly marked 
in ten of the thirty-one cases, all of which were of the comatose 
form. 1 In one case, of the algid variety, the cortical substance 
was paler than natural. In nine cases sections of the brain were 
immediately covered with numerous bloody points from the ori- 
fices of the cut vessels ; in a certain number, also, there was more 
or less venous engorgement of the superficial vessels, and a 

1 This alteration would seem to have been more frequent than is indicated by 
this proportion of cases in which it occurred. It is probable that Bailly mentioned 
it in his descriptions, only when it was strongly marked. It may be a matter of 
interest to my readers to see his remarks upon it. He says: "The brown color 
of the cortical substance was so generally present in those who perished with 
comatose fever, and in whom the coma returned with each successive paroxysm, 
during a great part of the summer, that I came at last so far to habituate myself 
to this shade as to consider it almost natural. Although I had formerly been 
especially occupied in France with the anatomy of the brain, and had thus fami- 
liarized myself with a type of the natural color of the cortical substance, as must 
always happen with those who labor constantly upon any similar subject; still, 
the habit of seeing none but the brains of these comatose patients, had at last 
substituted a new type for the old one. I therefore seized every occasion that 
presented itself of comparing these brains with those of individuals who had died 
with other diseases ; and then the enormous difference between the two classes 
became manifest. For pathological anatomy demands not only extensive observ- 
ations, but continual comparisons between healthy and diseased organs. Show 
the brain of a person who has died with comatose congestive fever to a physician 
but little in the habit of examining brains, and very certainly he will consider 
himself authorized to deny the alteration, which is quite evident to one who is fami- 
liar with the natural appearance of this organ. During the epidemic constitution 
of the year 1822, at Rome, there were fatal cases of phthisis, aneurism, dropsy, 
and so on, in which the brain was not implicated. Now, the cortical substance 
of the brain in these cases, when placed by the side of that of the fever patients, 
as I have noted in many instances, appeared white. In many instances, the mor- 
bid condition of organs is so slight or obscure that its existence maybe questiona- 
ble ; but this of which I am now speaking I have found so many times, and so 
constantly, and it has been so marked and evident, that not one physician in a 
thousand would have hesitated in admitting it." — Traite Anat. Path, des Fievres 
Inter. Par E. 31. Bailly, de Blois, p. 181. 



LESIONS. — BRAIX. 371 

moderate accumulation of serum; but all these changes are fre- 
quently found in other diseases, and, as has already been said, 
can hardly be regarded as peculiar or important. 

The following important additions to the pathology of the 
nervous centres in periodical fever, mostly of the pernicious form, 
are derived from the excellent and accurate work of Maillot. 
He examined the brain and its membranes in twenty-seven c 
In five cases, he found general opacity of the arachnoid ; in 
three cases, circumscribed opacity; in one case of icteric algid 
fever, the arachnoid had a yellowish tinge ; and in one case, 
where a quotidian fever had passed into a typhoid condition, the 
cavity of the arachnoid contained a sero-purulent collection. In 
eleven cases the pia mater was injected, more or less vividly, the 
arachnoid remaining natural ; in six other cases, both membranes 
were the seat of a vermilion injection; in most cases, the ve 
which run along the surface of the brain were strongly congested; 
many times the injection of the cerebral envelops was sufficiently 
fine to form patches, more or less extensive, of a vivid and bril- 
liant red. 

In twenty-two cases the cerebrum was more or less strongly 
injected, in most instances with a firmness and density that ap- 
peared to M. Maillot much greater than natural. Generally the 
substance of the brain exhibited a red color, very thickly dotted 
with bloody points; in some cases, of comatose and delirious 
fever, the cerebral mass was so strongly congested that, when 
compressed after having been divided, the blood flowed copiously 
from the cut surfaces. In eight cases the gray substance had a 
very dark color, in five of them approaching a blackish tinge ; 
in six cases the choroid plexus was of a deep red color; in ten 
cases the ventricles contained bloody serum. In one comatose 
case the brain was strongly injected, but soft ; in one icteric algid 
case it was slightly injected, of natural consistence, and of a 
yellow color ; in three other cases it was slightly injected, but 
without change of color or consistence. The cerebellum exhibited 
changes analogous to those of the brain, but less frequent than 
these. 

In fourteen cases the spinal pia mater was the seat of a ver- 
milion injection ; in five cases the pia mater and arachnoid were 
both injected; in one case of algid fever both had a yellowish 
color ; in one case their condition is not mentioned. In four 



372 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

cases the substance of the spinal marrow was generally injected 
and firmer than natural ; in one case it was less firm than natural, 
in one case the injection was very slight ; in three cases its con- 
sistence was natural without any injection; in two cases the in- 
jection was general, but it was much more strongly marked at 
the cervical and lumbar regions than elsewhere ; in one case it 
had a yellowish tinge, without any other alteration ; in four cases 
there was general injection, with red softening of the dorsal por- 
tion ; in three cases there was white softening of the dorsal por- 
tion ; in one case there was white softening of the cervical portion ; 
and finally, in one case, the injection of the gray substance, 
generally more considerable than that of the white, was very 
strongly marked in the cervical region, and carried to the red 
softening in the dorsal. In all these cases death took place in 
the acute period of the disease. Maillot says, in another place, 
that these lesions are found in all the varieties of pernicious fever; 
but that in the algid form he has found the cerebral congestion 
less strongly marked than in the comatose and delirious, while 
the spinal changes have been more so than in these. 1 In four 
cases, reported by Mr. Nepple, the lesions of the brain described 
by Bailly and Maillot were not observed. In two cases, reported 
by M. Raymond Faure, they were present. 2 

The fine injection of the membranes, the dark color of the 
cortical substance, and the general vascularity of the brain, would 
seem to constitute sufficient evidence of the previous existence at 
least of a high degree of irritation, approaching and in some in- 
stances perhaps passing into actual inflammation. The same 
remarks may be made in regard to the spinal marrow, and its 
envelops. 

ARTICLE III. 

LESIONS OF THE ABDOMINAL ORGANS. 

Sec. I. — Liver. I commence this article with a full account 
of the condition of the liver, because there is good reason for be- 
lieving that the lesions of this organ constitute the anatomical 
characteristic of the disease. For this discovery, and for the 

1 Traite, etc., p. 334. 2 Traite des Fievres Intermittentes, p. 283, et seq. 



LESIONS. — LIVER. 373 

special attention which has recently been directed to the state of 
the liver in periodical fever, we are indebted to Dr. Thomas Stew- 
ardson, of Savannah, Ga. Dr. Stewardson, before leaving Paris, in 
1834, had been made acquainted with the observations of Louis 
on the state of the liver in all the fatal cases of yellow fever exa- 
mined during the epidemic in Gibraltar, of 1828; and on his re- 
turn soon after to America he naturally felt a strong interest in 
ascertaining whether the same lesion was to be found in remittent 
fever — a disease regarded by many physicians as a mere variety 
of yellow fever. Opportunities for determining this interesting and 
important point of pathology soon presented themselves, and were 
zealously and faithfully made use of. Cases of periodical fever, 
in its several forms and degrees, are annually received into the 
Philadelphia hospitals, coming mostly from certain localities in 
Pennsylvania, and from the southern ports of the Atlantic, and 
occurring amongst sailors. During the years 1838, 1839, and 
1840, there were seven cases of the disease, which terminated 
fatally, and in which autopsies were carefully made. The first 
examination was made on the 9th of September, 1838, seventeen 
hours after the death of the patient. The form of disease was that 
most nearly approaching yellow fever. The liver was of natural 
size, flabby, and of a bronze color, becoming livid in the small 
lobe ; internally it was of a uniform light bronze color. The acini 
were distinguishable by a slight elevation, but there was no differ- 
ence of color in the two substances. The history of the condition 
of the liver is thus summed up by Dr. Stewardson : " The liver 
was enlarged in three cases, and in one of them to a great degree : 
in the others it was of natural or moderate size. The consistence 
of the organ appears to have been generally diminished ; being 
flabby or softened, or both, in four cases ; a little soft in a fifth; 
and moderately firm, but still readily penetrated by the finger, in 
a sixth ; in a seventh the consistence is not mentioned. The 
color was nearly the same in every case, but very different from 
natural. In most of the cases the liver is described as being of 
the color of bronze, or a mixture of bronze and olive ; in one as a 
dull lead color externally ; internally bronzed with a reddish 
shade ; in another as between a brown and an olive, the latter 
predominating ; and .finally as a pale, slightly greenish lead color, 
with a tinge of brown, in one instance. The most correct idea of 
the color before us would, perhaps, be conveyed by stating its 



374 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

predominant character, the same in every case, to be a mixture 
of gray and olive, the natural reddish brown being entirely ex- 
tinct, or only faintly to be traced. This alteration existed uni- 
formly, or nearly so, throughout the whole extent of the' organ, 
except in a single instance, where a part of the left lobe was of 
the natural reddish-brown hue. As the alteration of color per- 
vaded both substances, the two were frequently blended together, 
and the aspect of the cut surface remarkably uniform. In one 
case, however, there was a marked distinction of color, the olive 
being predominant in the parenchyma, the brown in the acini. 
Of the four cases in which these characters are mentioned, the 
cut surface is described as smooth in three ; of a shagreened ap- 
pearance, and rough in the left lobe, in the fourth. This last 
character was evidently dependent upon hypertrophy of the lighter 
colored substance, which existed also in another instance ; both 
cases, however, being examples of a very protracted form of the 
disease." 1 

In concluding the summary thus given, Dr. Stewardson very 
naturally suggests, at least the strong probability, that this alter- 
ation of the liver may be found to constitute the essential anato- 
mical characteristic of marsh fever, as the lesion of Peyer's 
glands, and the lymphatic ganglia, constitutes that of typhoid 
fever. He very properly, however, admits that the number of 
cases is n6t sufficiently large to determine this point conclusively ; 
and he refers its definitive settlement to future and more extended 
observations. In this connection, he states that, in the only case 
of marsh fever examined daring the year 1840, at the Blockley 
Hospital, by Dr. Gerhard, the liver presented the appearances 
which have just been described. 

The investigations which have been made and published, since 
the appearance of Dr. Stewardson's paper, are the following. 
In January, 1844, Dr. Wm. T. Howard communicated to Dr. 
Stewardson the history of a case which was observed in the 
Baltimore Almshouse, during the preceding season. " The liver 
was smooth externally, and of a uniform slaty, bronze color, 
marked with white striae through it. When cut into, it presented 
the same uniform slaty, olive, or bronze color, with the red and 
yellow substances confounded together, so as not to be distin- 

1 Stewardson on Rem. Fever. Am. Journ. Med. Sci., April, 1841. 



LESIONS. — LIVER. 375 

guished. It was moist when cut into, its vessels not much gorged 
with blood, and it was easily penetrated by the finger. No one 
portion was more changed than another." 1 

Dr. Swett's cases, observed in the New York Hospital, have 
already been referred to. Five of them were fatal; and in all, 
the peculiar change in the color of the liver, described by Dr. 
Stewardson, was present. Externally, this organ had a slaty and 
bronze tint, and an olive tint internally. Its volume was natural; 
in four cases it was slightly or moderately softened; in some 
cases the granular structure was less distinct than in a natural 
state, while in others it was not altered; in one case each gra- 
nule was surrounded by a ring of vascular injection. There was 
no unusual accumulation of blood. 2 

Dr. Alfred Stille' has published, in the American Journal of 
the Medical Sciences, for April, 1846, brief histories of twelve 
fatal cases of remittent fever, which occurred during the summer 
and autumn of 1844, in the Baltimore Almshouse Infirmary, and 
which were reported by Dr. W. F. Anderson, and Dr. Charles 
Frick. Setting aside two of the cases, on account of some doubt- 
ful or qualifying circumstances in their history, the condition of 
the liver in the other ten is thus summed up by Dr. Stille. " The 
size of the liver was noted in nine cases, in all of which, it was 
unnaturally large. Its consistence was very much diminished in 
ten cases, in eight of which the right lobe was the principal seat 
of the alteration ; in one the left lobe was chiefly affected, and 
in the remaining one the whole organ was softened. In all the 
color of the liver was either bronzed, or like that of slate; the 
surface of a section was polished or shining; and in every in- 
stance but one the different colors of its component parts could 
not be distinguished." 3 Dr. Stille' remarks, in the number of the 
Journal which contains these histories, that the same condition 
of the liver has been found in numerous dissections made at the 
several public institutions of Baltimore, during the fever season 
of 1845. 

The result of Dr. Boling's observations can hardly be regarded, 
in the present state of our information upon this subject, as of 
any great value; at any rate, these results are not sufficiently 

1 Am. Journ. Med. Sci., Jan. 1845. 

2 Swett on Path. Rem. Fev. Amer. Journ. Med. Sci., Jan. 1845. 

3 Ibid., April, 1846. 



376 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

authentic and conclusive to throw any reasonable doubt upon the 
conclusions of Dr. Stewardson, Dr. Swett, and others. He says 
that, not having found the changes in the liver which he had 
looked for, he was led to believe that lesions of this organ were 
less frequent than of almost any other. On the appearance of 
Dr. Stewardson's paper his attention was again directed to the 
liver, but he has been able, he says, in but a very few instances 
to find any alteration, the organ in a large proportion of cases, 
so far as he was capable of judging, being entirely healthy. 
Where it was otherwise, he found the concave surface of the 
liver of a bluish slate color. Dr. Boling does not give any de- 
tailed histories of his autopsies; he speaks of himself as not 
accustomed to frequent post-mortem examinations ; and, as I have 
already intimated, it will be considered, in the actual state of our 
knowledge, as a perfectly fair judgment, that these cases shall, 
provisionally, at least, be set aside, and not be allowed to have 
any effect on the settlement of the question before us. Maillot 
describes the liver in nine cases as congested ; in three cases as 
easily torn; in one case as friable; in three cases as yelloivishi 
pale, and somewhat softened; once as greenish yellow; once as 
chocolate colored; and in five cases as natural. In five other 
cases its condition is not mentioned. 1 

It would be hardly worth the time and room necessary for this 
purpose, to go into any detailed account of the pathological re- 
searches of older writers upon this family of diseases. The 
Italian authors — Baglivi, Lancisi, Torti, Ramazzini, etc. — the 
great classics in this department of medicine — are not at our 
hand; and if they were, they would be of little service, as they 
are said to give but meagre and unsatisfactory details in regard 
to the state of the organs after death. Greorge Cleghorn, in his 
admirable little treatise on the diseases of Minorca, written more 
than a hundred years ago, says that he had examined the bodies 
of near a hundred persons who had perished with tertian fevers, 
and had constantly found " one or other of the adipose parts in 
the lower belly — the caul, mesentery, colon, etc. — of a dark black 
complexion, or totally corrupted." Bailly, in his elaborate and 
interesting history of the pernicious intermittents of Rome, re- 
ports a large number of autopsies ; but in many of them the liver 

1 Traite des Fieyrcs Intermittentes, p. 285. 



LESIONS. — SPLEEN. 377 

is not mentioned ; in others it is said to have been gorged with 
blood; and in others it is called natural. It need hardly be said, 
that the overlooking by these writers, and under such circum- 
stances, of a lesion like that under consideration, is no proof that 
it did not exist. 1 

There seems to be no uniformity in the character of the bile 
contained in the gall-bladder. Dr. Stewardson found it gene- 
rally abundant and very fluid ; while in nearly all the cases re- 
ported by Dr. Swett, Dr. Anderson, and Dr. Flick, it was dark, 
thick, and viscid, like molasses. Bailly rarely mentions the ap- 
pearance of the bile. 

As to the nature of the lesion of the liver just described, it is 
impossible, in the present state of science, to say much, without 
running into the merest speculation. "We have no right to con- 
sider it inflammatory. It may be the result of repeated conges- 
tions ; but it is more philosophical for the present, to say simply. 
that it seems to be sui generis — to consist in an alteration of a 
special and peculiar character, the nature and mechanism of 
which are quite unknown to us. It is probably connected in 
some way with the poison of periodical fever — alike unknown 
to us — and it may be the result of the action of this poison upon 
the system, or of the morbid processes to which the poison gives 
rise. 

Sec. II. — Spleen. The spleen is almost always enlarged, soft- 
ened, and of a very dark or bluish black color. This lesion is 
so constant, and has been so long familiar to all observers of this 
class of diseases, that it is hardly necessary to multiply cases or 
to quote authorities. In some instances the volume of the organ 
is enormously increased. In one of Drs. Anderson and Frick's 
cases it weighed three pounds, in one of Dr. Swett "s cases it was 
nine inches long and four thick. Bailly mentions instances of 
its weighing eight or nine pounds. It is often so much softened 
as to consist merely of a sort of half-fluid putrilage — a dark 
pulpy mass apparently destitute of organization. Dr. Bailly re- 
ports several cases in which these changes in the state of the 
organ resulted in a rupture of its enveloping membrane, and the 

1 Prost is said to have exhibited the extensive intestinal lesions of typhoid 
fever in bodies which had been examined by Pinel and Corvisart, and the altera- 
tions wholly overlooked. 



378 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

consequent escape of its softened contents into the peritoneal 
cavity. Maillot saw but one instance of rupture of the spleen, 
in Africa. He suggests that its greater frequency in Italy may 
depend upon the less active means adopted there to prevent local 
congestions. Dr. Boling thinks that these alterations of the 
spleen are rather the consequence of what he calls the latent 
action of malaria than the immediate and direct result of the 
disease. He says he has never found any evidences of enlarge- 
ment during life, nor any morbid appearance in the organ after 
death, in a first attack of remittent fever, in a person who had 
not previously resided some considerable time in a malarious 
region. He believes the alterations to take place gradually from 
the effects of the febrile poison upon the system, and that they 
are merely increased by the febrile attack itself. 1 This condition 
of the spleen is probably the result of violent and repeated con- 
gestions. 

Sec. III. — Stomach. The condition of the stomach has not 
been ascertained with a sufficient degree of accuracy, and in a 
sufficiently large number of instances, to settle definitely the part 
which its lesions play in the pathology of remittent fever. Its 
mucous membrane presents, in a large majority of cases, marks 
more or less extensive and striking of inflammation. It is 
generally reddened and vascular ; sometimes over certain por- 
tions only, and at others throughout the whole extent of its sur- 
face. This redness is sometimes continuous and uniform, some- 
times in patches; in some cases arborescent, and in others 
pointed 0/ dotted. The consistence of the membrane is also 
sometimes diminished ; and in many cases it is mamellonated. 
In five of six cases reported by Dr. Stewardson, marks of inflam- 
mation were present; — mamellonation, in three; thickening, in 

1 This opinion of Dr. Boling induces me to record here, in a note, a patho- 
logical fact that may have some bearing upon the subject. During the winter of 
1844, a patient died in the Baltimore Almshouse with simple pneumonia. He 
came from the Mine Banks, a locality celebrated for the number and severity of 
its marsh fevers. He had resided there during the sickly season, but was not 
known to have had the fever. In addition to the lesion of the lungs, his liver 
presented the alterations already described as belonging to remittent fever. I 
suggested at the time the possibility, at least, that the change in the liver might 
have been the result of the gradual and long-continued action upon the system of 
the febrile poison. 



LESIONS. — STOMACH. 379 

two; thinning throughout, in one; in the great cid-dc-sae, in 
another; softening in two, and changes of color in several. In 
one or two instances the lesions were very slight. 1 The mem- 
brane was injected in seven of nine cases reported by Anderson 
and Frick — in three of them intensely. In five cases it was 
softened near the cardiac extremity, and in four near the pylorus ; 
where also it was for the most part grayish, thickened, and 
mamellonated. 2 Dr. Swett found nearly similar alterations; but 
he is disposed to regard them as less important than they are 
considered to be by Dr. Stewardson. "Most of the changes," 
he says, " that I have observed in the mucous membrane of the 
stomach have appeared to me of a chronic nature, and probably 
long antecedent to and entirely independent of the acute di> 
I refer particularly to the thickened and mamellonated condition 
of the organ. The injection of the mucous membrane, although 
present in all the cases to a certain extent, did not appear to me 
beyond what is commonly noticed in other acute diseases, and 
might in some cases, at least, be referred distinctly to simple 
post-mortem venous congestion." 3 Of thirty-one cases of malig- 
nant intermittent, or congestive fever, occurring at Home, and 
reported by Bailly, the stomach is described as presenting marks 
of inflammation, more or less extensive and intense, in twenty- 
six ; in some cases the mucous membrane was thickened ; in some 
mamellonated, and in many thickly covered with a layer of 
viscid, tenacious mucus, adhering pretty firmly to the membrane 
itself. 4 The stomach is not unfrequently contracted upon itself, 
its inner membrane thrown into prominent folds, and its cavity 
containing a moderate quantity of fluid of a yellowish, brownish, 
or greenish color. 

Maillot examined the mucous membrane of the stomach care- 
fully in twenty-eight cases, most of them belonging to the perni- 
cious form of the disease. In only one was the membrane 
entirely healthy. In five cases he found gray, slate-colored 
softening, without any red injection; in one case gray, slate- 
colored softening, with pointed redness; in eleven cases gray, 
dirty softening, with red injection; in one case gray, dirty soft- 
ening, without redness ; in four cases reddish softening; in two 

1 Amer. Journ. Med. ScL, April, 1841. 2 Ibid., April, 1846. 

3 Ibid., Jan. 1815. 4 Bailly on Inter. Fevers. 



380 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

cases reddish-brown softening ; in one case blackish softening, 
without injection; in one case where death was occasioned by 
rupture of the spleen, very slight recent injection, with a gray 
tint ; and in one case of typhoid affection, the red injection, with 
softening, common in acute gastro-enteritis. I have already 
spoken of Dr. Swett's opinion in regard to the character of these 
gastric lesions. Maillot has arrived at a similar conclusion. He 
thinks it quite clear that, in most cases, the alterations, especially 
the softening with gray, brown, and slate coloration, extending 
to large portions of the membrane, are the result, not of recent 
acute inflammation, but of chronic irritation, preceding the attack 
of the febrile disease. The difference between the result of his 
observation and that of Bailly's he believes to be more apparent 
than real. 

Sec. TV .—Intestines. Although our knowledge of the lesions 
of remittent fever is far enough from being full and complete; 
and although there are some apparent differences in the results 
of recent observation in regard to the condition of the mucous 
membrane of the alimentary canal, we are justified, I think, in 
saying that there is no satisfactory evidence that this membrane 
is the seat of any constant, important, or characteristic altera- 
tion. Dr. Stewardson has called the attention of the profession 
to a condition which he supposes may be peculiar to this disease ; 
— I mean, an enlargement of the mucous follicles of the duode- 
num, or the glands of Brunner, as they are called. He found 
these glands remarkably distinct in all the six cases, where the 
duodenum was particularly examined. 1 In all the twelve cases 
reported by Anderson and Frick, Brunner's glands were also 
unusually developed, and in three of them to a remarkable 
degree. 2 Dr. Swett, on the other hand, did not find, in his five 
cases, any change in the state of these glands which he could 
look upon as morbid. 3 . 

The elliptical plates of the small intestines, commonly called 
Peyer's glands, are, so far as the most authentic and trustworthy 
observation enables us to determine, uniformly free from any 
well-marked morbid alteration. This, at any rate, is the conclu- 

1 Amer. Journ. Med. Sci., April, 1841. 2 IbicL, April, 1846. 

3 Ibid., Jan. 1845. 



LESIONS. — INTESTINES. 381 

sion which I myself, in the present state of our knowledge, and 
after a careful examination and estimate of all the evidence 
within my reach, feel compelled to adopt. But as the question 
of the condition of these glands is one of so much pathological 
interest and importance ; as it has a direct bearing upon the re- 
lations of bilious remittent to other forms of fever, and as it may 
fairly enough be regarded as not finally and definitively deter- 
mined, I will state briefly, but completely, the results of recent 
observation upon this matter. Dr. Gerhard examined particu- 
larly and carefully the state of Peyer's glands, in two cases of 
remittent fever, as long ago as 1834; and he found them in both 
entirely free from the slightest alteration. In the seven fatal 
cases which constitute the material and basis of Dr. Stewardson's 
paper on the lesions of this disease, the glands of Peyer were 
uniformly healthy. They are described in some cases as distinct, 
and well defined in their outline, honeycombed on the surface, 
or dotted with depressed points, and these latter sometimes of a 
dark color ; but uniformly free from thickening, softening, ulce- 
ration, or any other obvious and unequivocal alteration. 1 In Dr. 
Swett's cases, " the glands of Peyer were very distinct from 
their pale white color, contrasting strongly with the dirty hue of 
the surrounding mucous membrane, but neither thickened, soft- 
ened, nor injected." 2 In two of the twelve cases reported by 
Anderson and Frick, the elliptical plates were either not ex- 
amined, or are not mentioned ; in the remaining ten they were 
generally pretty distinctly visible, but free from any decided 
disease. 3 

These results may seem to be in contradiction to certain other 
observations on the same subject. In the Neiv York Journal of 
Medicine and Surgery ', for 1839, Dr. Richardson, resident physi- 
cian of the New York Hospital, has published the pathological 
histories of six cases of what was regarded by him as remittent 
fever; in all of which, Peyer's glands are alleged to have been 
diseased. In three they are said to have been enlarged, but not 
ulcerated ; in one there were numerous small ulcers on one of the 
plates ; and in two there were more or less extensive and un- 
equivocal ulcerations — the ulceration in one of these having 

1 Amer. Journ. Med. Sci., April, 1841. • 2 Ibid., Jan. 1845. 

a Ibid., April, 1846. 



382 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

extended through all the coats of the intestine. My attention 
was called to these cases, by a medical friend, very soon after 
their publication, on account of the contradiction which they 
appeared to furnish to one of the most generally received and 
well established opinions in regard to the intestinal lesions of 
typhoid and of remittent fever. I studied them with great in- 
terest, and with great care ; and was immediately and thoroughly 
convinced that the deductions which had been made from them 
were wholly gratuitous and unfounded. It was quite clear that, 
in the two cases, in which extensive and unequivocal ulceration 
was present, either the diagnosis was manifestly wrong, or there 
was no sufficient ground for regarding them as cases of remittent 
fever; while in all the others, in which the diagnosis was most 
probably correct, there was no sufficient evidence of any morbid 
condition of the elliptical plates. This whole matter has since 
been placed in its true light, and the importance of these cases 
reduced to its proper position, by Dr. Swett, in the American 
Journal of the Medical Sciences for January, 1845. If these 
cases do not furnish any additional evidence of the wide differ- 
ence between typhoid and remittent fever, so far as the condition 
of Peyer's glands is concerned, they do not at least furnish any 
evidence of a contrary character. They have one value, how- 
ever ; and that consists in the lesson they teach us — a lesson that 
can hardly be too frequently or too emphatically repeated — of 
the great danger, in all questions requiring careful observation 
and rigorous analysis, of trusting in any the slightest degree to 
incomplete, inadequate, or equivocal facts. Such facts, under 
such circumstances, so far as the interests of true science are 
concerned, are worse than none, inasmuch as ignorance is better 
than positive error; and as it is safer and more profitable to 
stand still in the dark, than it is to follow a false light in the 
wrong direction. 

Dr. Boling reports two cases in which he found ulceration of 
the elliptical plates. The history of the cases is not given ; but 
in one of them, we are told that the fever was of about forty days' 
duration ; in the other the case terminated on the ninth day, and 
was attended by diarrhoea. I have already had occasion to ex- 
press the opinion that some of the cases alluded to by Dr. Boling, 
in his description of the symptoms of bilious fever, were cases of 
typhoid fever ; this I believe also to have been true of the two 



LESIONS. — GENERAL REMARKS. 383 

cases just spoken of. At any rate, the most that we can do with 
them is, to set them aside, or to place them in the category with 
those of Dr. Richardson. 1 

As to the mucous membrane generally, both of the small and 
large intestines, there is no evidence that it is more than occa- 
sionally and accidentally altered. Bailly describes it, in most of 
his cases, as more or less extensively inflamed; and the same 
thing is true of some other observers. It is quite clear, however, 
that, in many of Bailly's cases, the presence of a few patches of 
increased redness or vascularity was the only proof of the pre- 
vious existence of inflammation. According to the researches of 
all the more recent and accurate observers, the changes found in 
the general intestinal mucous membrane, after death from periodi- 
cal fever, are only those customary and accidental lesions, found 
with the same frequency after death from many other acute febrile 
affections. I am not aware that there is anything peculiar in 
the contents of the alimentary canal. The mesenteric glands are 
generally without alteration ; the same thing is true of the kidneys 
and the bladder. 

Maillot found in fifteen cases, the mucous membrane of the 
small intestines softened, with a gray, brown, or slate tint, with 
or without recent injection ; in one case softened with bright red- 
ness; in twelve cases the elliptical plates with the honeycomb 
development, in three of which the surface of the plates resembled 
the newly-shaven chin ; in eleven cases, some development of the 
isolated follicles ; once only ulcerations ; in four or five other 
cases slight changes; and in four cases no lesions whatever. 2 

ARTICLE IV. 

GENERAL REMARKS. 

Sec. I. — Relation of Lesions to Symptoms. It is sufficiently 
demonstrated by the foregoing details, that periodical fever does 
not often destroy life without leaving behind it very decided and 
somewhat extensive anatomical lesions. As I have done in re- 

1 Since -writing the above, I have had a correspondence with Dr. Boling in 
regard to the most striking of these two cases. His letter to me contains nothing 
to induce me to change the opinion already expressed in regard to the true cha- 
racter of these cases. 

2 Traite des Fievres Intermittentes, p. 2S4. 



384 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

gard to the fevers already treated of, I propose here to say a few 
words about the connection between the symptoms of the disease 
on the one hand, and these lesions on the other. This connec- 
tion, so far at least as the more constant and important pathologi- 
cal alterations are concerned, would seem to be pretty uniform 
and direct. We can hardly hesitate, I think, for instance, in 
referring the nausea, vomiting, and epigastric distress, so nearly 
always present, to the disorders of the mucous membrane of the 
stomach, resulting in the changes that are found after death. So, 
the moderate fulness across the upper part of the abdomen, with' 
the tension, the feeling of weight and oppression, in each hypo- 
chondrium, and especially in the left, are evidently connected 
with and dependent upon the congestion of the liver and spleen, 
resulting in the alterations which these organs constantly exhibit. 
In the same way, it is impossible to doubt that the coma and 
delirium are intimately and directly connected with the striking 
lesions usually found in the brain and its membranes ; and if the 
relationship here sometimes fails — if it is not absolutely inva- 
riable — this is only what happens occasionally, even with the 
best established and most constant of these relations, in other dis- 
eases. M. Maillot thinks that the algid symptoms — the failing 
circulation, and the icy coldness — are especially and immediately 
connected with the lesions found in the spinal marrow and its 
membranes. 1 

I do not see any reason to suppose that the lesions of periodi- 
cal fever follow any fixed or uniform order of succession in their 
development. The congestions and irritations of the several 
organs and tissues, which bear the chief burden of the dis- 
ease, are in many cases evidently simultaneous in their origin — 
occurring together; in others the weight of the disease, to use 
the favorite phraseology of the older writers, falls principally 
upon one organ — the brain, for instance ; in still others, upon 
some other organ — the stomach, the liver, or the spleen ; — and 
all this without anything that is constant or regular. 

Sec. II. — Importance — Relative and Absolute. The relative 
and absolute importance of the appreciable lesions in periodical 
fever — the part which they severally play in the production of 

1 Traite des Fievres Intermittentes, p. 329. 



LESIONS. — GENERAL REMARKS. 385 

the aggregate phenomena of the disease, and the share which 
each of them contributes towards the fatal issue, in fatal cases, 
are matters which can be only approxiniatively and in some de- 
gree conjccturally determined. "We can hardly doubt that a 
sudden and overwhelming congestion of the cerebro-spinal axis 
will be attended by greater danger than a corresponding conges- 
tion of the liver and spleen ; but to attempt to go much beyond 
a few obvious and manifest conclusions, similar to this, and nicely 
to gauge and measure the agencies of each pathological alteration, 
would be but an idle and profitless labor. 



25 



386 



CHAPTER IV. 

CAUSES. 

Sec. I. — Locality. There is probably no form of endemic 
disease the geographical boundaries of which are so extensive as 
those of periodical fever. With certain limited -exceptions, it 
may be said to encircle the earth in a broad belt, parallel with 
the equator, its northern and southern boundaries quite irregular 
in their disposition — now approaching to the line of the tropics, 
and now receding from it. The portions of this immense terri- 
tory which are entirely exempt from periodical fever increase 
with the distance from the equator ; while within the tropics, and 
along the range of several degrees beyond them, these portions 
are confined mostly to certain geological formations, and to ele- 
vated situations. The particular regions most extensively and 
constantly the seat of this disease in its more malignant forms, 
are low-lying and wet lands, situated in hot climates, and covered 
with a rank and spontaneous vegetation — the flat, wooded sea- 
coasts ; the interior swamps and marshes ; and the rich alluvions 
of the deltas and courses of the great rivers. It is hardly worth 
while to make a detailed enumeration of all these individual lo- 
calities. I shall confine myself to a few statements in reference 
to the distribution of malarious fevers throughout the different 
portions of the United States, for which I am mostly indebted 
to the researches of the late Dr. Forry. 

These statements are founded upon data furnished by official 
records in the Medical Department of the United States, and in 
the Adjutant- General's office. They extend over a period of ten 
years ; and they exhibit the actual and relative prevalence of 
periodical fever amongst the soldiers in the several military sta- 
tions of the country. In these several classes of stations, the 
ratio of cases, annually, of intermittent fever, in each one thou- 
sand of mean strength, was as follows : On the coast of New 
England, 36 ; on the northern chain of lakes, 193 ; in posts north 



CAUSES. — LOCALITY. 38T 

of latitude 39°, and remote from the ocean and inland seas, 151 ; 
on the sea-coast, from Delaware Bay to Savannah, 370 ; in the 
southwestern stations, including Jefferson Barracks, Forts Gibson, 
Smith, Coffee, Towson, and Jessup, 747 ; on the Lower Mis- 
sissippi, 385 ; and in the peninsula of East Florida, 520. These 
averages, derived from sufficiently large numbers, and running 
through a period of ten years, with one or two explanations and 
qualifications, may be safely taken as a true exponent of the re- 
lative prevalence of this form of fever, in these several regions 
of country. The apparent ratio in the New England division, 
low as it is, is still vastly too high ; since all or nearly all these 
cases originated in some of the other divisions. It may be re- 
marked here, incidentally, that Nova Scotia and New Brunswick, 
in the British dominions, are entirely free from intermittent 
fever, while in Upper Canada the disease prevails very exten- 
sively, although there is no difference in the climate or soil of 
these regions, to account for the circumstance. 

The ratio of remittent fever, according to Dr. Forry, through- 
out the same regions, is as follows : On the coast of New England, 
26; on the northern chain of lakes, 33; in posts north of lati- 
tude 39°, and remote from the ocean and inland seas, 24 ; on the 
sea-coast from Delaware Bay to Savannah, 181 ; in the south- 
western stations, 180; on the Lower Mississippi, 196; in East 
Florida, 102. The diagnosis in the present case is less to be 
relied upon than in that of intermittent fever ; it is probable that 
most of the cases reported in the New England division were 
continued in their type, and not periodical. 

The only considerable portion of the vast and various territory 
now occupied by the United States which is quite exempt from 
malarious fever, is to be found in its extreme northeastern corner, 
constituted by the five New England States, and a large part of 
the State of New York. From nearly the whole of this region 
periodical fever has almost entirely disappeared. That it was 
sufficiently common here for a long period after the settlement of 
the country has been clearly shown, by the very careful and 
thorough inquiries of Dr. 0. W. Holmes, contained in his prize 
essay upon this subject. There are still a few small localities, 
mostly along the valley of the Housatonic, in Massachusetts. 
where a solitary case of domestic origin may be still occasionally 
met with ; but, with these exceptions, the disease is never seen in 



388 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

any of the New England States. Throughout the remaining 
portions of the country, the disease prevails with great irregu- 
larity of extent and severity. Large portions of some of the 
States — those particularly which are most thoroughly cultivated, 
and the higher granitic regions, with the dry, pine country of the 
South, are to a great extent free from the disease ; and this free- 
dom is gradually extending its area with the progress of cultiva- 
tion. 1 

As a general rule, the simple intermittent form of the disease 
predominates throughout the cooler and more temperate regions ; 
in the warmer climated, and during the latter part of the hot sea- 
son, the bilious remittent variety becomes more common, inter- 
spersed with occasional cases of the pernicious or congestive va- 
riety — the latter becoming more frequent in the more southern 
regions, and especially along the low, rich river bottoms, and 
swampy lagunes. Dr. Lewis, of Mobile, says, the low lands in 
the State of Alabama, lying along the creeks, known as the 
slough prairie, the swamps, and reed marshes, have proved to be 
more certain and prolific sources of disease than other formations 
— the low alluvions of the river bottoms not excepted. Some of 
these localities, as the reed marshes in Green county, though 
very fertile, have been abandoned. There are said to be farms, 
near the junction of the Bigby and Alabama rivers, upon which 
no white man can permanently reside. 2 

There are many other regions where the disease is not less 
common and malignant. Lind says, Hungary has been properly 
called the grave of Germany. A very striking instance of the 
power and intensity of the febrile poison, on the western coast 
of Africa, will be found in the chapter on bibliography. Dr. 
Nicolle, in a report made in 1821, says : "About one in twelve, or 
very nearly nine per cent, of the better class of society, died last 
year in Sierra Leone ; and it appears from official documents in 
the office of the secretary of government here, that such has 
been the average annual mortality from the census of Europeans 
in this colony. On the 31st of December, 1818, there were one 
hundred and twenty-eight, of whom eighteen sailed before the 

1 At the beginning of the present century, of one hundred men employed at 
the Onondaga salt works, in New York, ninety-eight were attacked with bilious 
remittent fever. Many of the cases Avere fatal. — Edward Miller's Works, p. 97. 

2 Lewis's Med. His. of Alabama, p. 10. 



CAUSES. — SEASON. — TEMPERATURE. — WEATHER. 389 

rainy season, for England, two of whom died ; and of the remain- 
ing number — one hundred and ten — eight perished. 1 Mr. Tidlie 
says : " The exceptions are very few, where Europeans have 
passed twelve months in the country from England without an 
attack of the fever. In the year 1819, there were, at Cape 
Coast Castle, eight new-comers from England, all of whom were 
seized with the fever, and three died ; and out of forty, the total 
strength of Europeans in the service of the late African com- 
pany, five died. In 1820 and 1821, there were eleven new- 
comers, all of whom were attacked, and four of whom died.'' 2 

Another of the most celebrated malarious regions of the old 
world is to be found in the middle and southern portions of Italy ; 
and hardly in Africa itself, along the delta of the Niger, is the 
malarious poison more concentrated and malignant than it is here. 
Many a traveller has lost his life by a night ride over the Pontine 
Marshes. Bailly estimates that one-tenth of the population of 
Rome are annually attacked by disease, and that two-thirds of 
these suffer from periodical fever. Some of our best and earliest 
histories of the disease were from Italian pens — those of Torti, 
Lancisi, Ramazzini, &c. In 1818, there were consumed at the 
hospital of the Holy Spirit, at Rome, between the months of June 
and October, inclusive, three thousand and two hundred pounds 
of cinchona. 3 

Sec. II. — Season; Temperature; Weather. There can be no 
doubt, as I have already said, that, other things being equal, 
periodical fever increases in frequency and gravity with an in- 
crease in the heat of the climate or locality. The simpler and 
milder form of the pure intermittent type is most common in the 
more northerly and cooler regions, and in the cooler seasons of 
the year ; while the remittent and congestive forms are mostly 
confined to the hotter regions and seasons. M. Maillot shows 
conclusively, by extensive and accurate tables, that the frequency 
and intensity of visceral irritations and congestions increase in a 
constant and direct ratio with the elevation of the atmospheric 
temperature. He says, further, that the dry and hot season, in 
Africa, is marked by irritations of the brain and of the upper 

1 Boyle's Dis. West. Africa, p. 149. 2 Ibid,, p. 152. 

3 Traite, etc, par Bailly, p. 139. 



390 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

portion of the alimentary canal, while the wet season brings with 
it bronchitic and dysenteric complications. 1 

Throughout the United States, the great season for all the forms 
of periodical fever may be said to extend from the middle of sum- 
mer to the close of autumn — varying, of course, somewhat, in 
different years and in different places. Dr. Wilcocks treated, 
during the season of 1846, in Philadelphia, one hundred and 
seventy-one cases of remittent and intermittent fever ; — in July, 
ten cases; in August, eleven; in September, ninety-nine ; and 
in October, fifty-one. 2 On the western coast of Africa, the largest 
number of cases occur near the commencement and the termina- 
tion of the rainy season — March and September. 3 At Rome, the 
disease prevails most extensively during the months of August, 
September, and October. 4 

In regard to the influence of the prevailing character of the 
season, there is a general impression that hot and wet weather 
promotes the prevalence of marsh fevers, while cool and dry 
weather prevents it. This impression is probably in some degree 
well founded ; although the connection between the obvious quali- 
ties of the season and disease, are far enough from being fixed 
and uniform. Some observers, indeed, deny this connection 
altogether. 

Dr. Cooke, of Opelousas, in a paper on congestive fever, says: 
" We have seen our country enjoying one year extreme good 
health, notwithstanding the long continuance of the most intense 
heat, superabundance of rain, and easterly winds ; another year, 
under similar circumstances, it has been ravaged by disease ; — 
other years, when anticipating good health, in consequence of a 
moderate temperature, a uniform season, and moderate rains, 
without prevailing east winds, we have also had to sustain the 
most extensive visitation of disease. No one, in this section of 
the country, resting on experience or observation, can designate 
any infallible circumstances as productive or promotive of sick- 



Sec. III. — Age. The influence of age upon the occurrence of 
malarious fever does not seem to have been very particularly 

1 Traite des Fievres Intermittentes. Par F. C. Maillot, p. 20. 

2 Amer. Journ. Med. Sci., Jan. 1847. 3 Boyle's Dis. West. Africa. 

4 Bailly, p. 134. e N. 0. Med, Journ., vol. ii. p. 180. 



CAUSES. — SEX. — RACE. 391 

studied. It certainly may occur at all ages. It is more common 
during adult life than it is earlier ; and this may in part at least 
depend upon the greater degree of exposure. Cleghorn says 
malignant tertians are most common amongst adults, and those of 
an advanced age. 1 Dr. Charles Parry, in his paper on conges- 
tive fever, says : " This disease is confined chiefly to adults of 
both sexes ; children are rarely affected. I never saw a case in 
an individual under twenty years of age." 2 Dr. Wharton, of 
Mississippi, says, of congestive fever : " Children under ten years 
of age are comparatively free from its ravages ; and persons from 
twenty to thirty are most subject to it." 3 Dr. Lewis, of Mobile, 
on the other hand, thinks that the liability to congestive fever is 
alike at all ages, and that its greater frequency amongst male 
adults is entirely owing to the greater and more frequent exposure 
of this class to the malarious poison. 4 

Sec. IV. — Sex. There are more cases of periodical fever, in 
all its forms, amongst males than amongst females ; but the differ- 
ence in the degree of exposure of the two sexes to the causes of 
the disease are sufficient to account for this result. 

Sec. V. — Race. The negroes of malarious regions are less 
subject to their fevers than the whites. 

Dr. Lewis, in his paper on the yellow fever of Mobile, makes 
the following remarks, in connection with this subject: "I will 
now travel so far out of my course as to give a few of the facts 
which have been gathered concerning the liability of the negro 
race to other diseases indigenous to Alabama. I practised two 
summers in the interior of the State ; during the autumnal months, 
congestive fever prevailed so generally in my neighborhood as to 
amount to an epidemic ; — there were in my professional circle two 
blacks to one white, yet I did not see a single case of congestive 
fever in a negro, nor did I hear that any died of the disease in 
that section of country. I have made inquiries of several medical 
gentlemen who have been practising for many years in the country; 
their experience does not materially differ from mine. The fact 
is, that the remarkable exemption from yellow fever, which this 

1 Bush's Cleghorn, p. 106. 2 Amer. Journ. Med. Sci., July, 1843. 

3 Ibid., April, 1844. 4 Med. Hist, of Ala., p. 26. 



392 PERIODICAL FEVER. 

race enjoys, extends, in a great measure, to all the malarious 
fevers of hot climates ; — they may all have intermittent and light 
"bilious fevers, as well as the milder grade of yellow fever, but it 
is only under extraordinary circumstances that these diseases 
affect them so seriously as to cause death." 1 The same writer, 
in his Medical History of Alabama, speaking of congestive fever, 
says : " Of twenty-five correspondents, residing in different sec- 
tions of the State, two-thirds aver that, with the limited exposure 
to which the whites are subjected, negroes would not have the 
disease." A very striking instance of the exemption of the negro 
race from these forms of disease is found in the history of the late 
disastrous expedition of the British government up the Niger, no- 
tice of which will be found in the chapter on bibliography. 

Sec. VI. — Exposure ; Excesses, $c. There is no room what- 
ever to doubt the agency of the ordinary exciting causes of dis- 
eases in bringing on an attack of marsh fever. The poison of the 
disease very frequently lies dormant in the system until it is 
suddenly kindled into activity by the action of some one of these 
causes. The most active and important amongst them are — ex- 
posure of the body to cold, after it has been heated ; exposure to 
intense heat ; fatigue ; and all excessive indulgences. 

Sir Gilbert Blane says : " If I were required to fix on a circum- 
stance the most pernicious of all others to Europeans, particularly 
those newly arrived in the West Indies, I would say that it is 
exercise in the sun. The practice most hurtful next to this is 
intemperance in drinking, and to one or both of these the sick- 
ness and mortality amongst new-comers may be ascribed." 2 

It is important, however, to add, that where the poison of the 
disease is very active and concentrated, it overbears all resisting 
influences, and does not require the co-operation of any of these 
occasional causes. Hillary, in his account of the diseases of 
Minorca, says : " Surprising as it may appear, it is nevertheless 
true, that the peasants, who are remarkable for temperance and 
regularity ; and the soldiers, who, without meat and clothes, fre- 
quently lie abroad drunk, exposed to all weathers, have diseases 
almost similar, both as to their violence and duration. Hence it 

1 ». 0. Med. Journ., vol. i. p. 416. » Qbs. Dis. of Seamen, p. 226. 



CAUSES. — MALARIA. 393 

is evident how far the power of the air is superior to that of the 
other non-naturals in producing disorders of the animal economy." 1 

Sec. VII. — Malaria, The essential, efficient, producing cause 
of periodical fever — the poison, whose; action upon the system 
gives rise to the disease — is a substance, or agent, which has re- 
ceived the names of malaria and marsh miasm. The nature and 
composition of this poison are wholly unknown to us. Like most 
other analogous agents — like the contagious principles of small- 
pox and typhus, and like the epidemic poisons of scarlatina and 
cholera — they are too subtile to be recognized by any of our 
senses; they are too fugitive to be caught by any of our contri- 
vances. Neither the strongest lenses of the microscope, nor the 
nicest analyses of chemistry have succeeded in discovering the 
faintest traces even of the composition and character of these 
invisible, mysterious, and stupendous agencies. As always hap- 
pens in such cases, and under similar circumstances, in the ab- 
sence of positive knowledge we have been abundantly supplied 
with conjecture and speculation ; — what observation has failed to 
discover, hypothesis has endeavored and professed to supply. It 
is quite unnecessary even to enumerate the different substances 
to which malaria has been referred. Amongst them, are all the 
chemical products and compounds possible in wet and marshy 
localities ; moisture alone ; the products of animal and vegetable 
decomposition ; and invisible, living organisms. 

In regard to the alleged agency of animal and vegetable de- 
composition in the production of the poison of periodical fever, 
I have but little to say, and this for the simple but sufficient rea- 
son that we have no positive knowledge upon the subject. Un- 
questionably there is a very active decomposition, both of vege- 
table and of animal substances, usually going on in malarious 
localities; it is possible enough that this decomposition may 
produce the poison ; but there is no positive evidence yet that it 
does so ; and there are some reasons for doubting it altogether. 
One of these reasons is to be found in the common and notorious 
fact that this same decomposition is constantly going on without 
giving rise to periodical fever. 2 The hypothesis of the animal- 

1 Husk's Hillary, p. 42. 

2 Bailly says that, in 1822. Rome was visited by immense numbers of large 
grasshoppers, so that the streets and fields were covered with them, living and 



394 PERIODICAL FEVER. 

cular or cryptogamic origin 'of this and of some other endemic 
and epidemic diseases is an old one, which has been recently re- 
vived, and advocated with great ingenuity and ability. It is only 
a hypothesis ; but it may be safely said of it, I think, that it may 
be made to correspond to the ascertained phenomena in connec- 
tion with the etiology of these diseases, better than most other 
hypotheses ; and that it is less embarrassed by objections which 
cannot be met, and by difficulties which cannot be overcome. 

Inscrutable, however, as the intimate nature of this substance 
or agent may be, there are some few of its laws and relations 
which are very well ascertained. One of these consists in its 
connection with low and wet, or marshy, localities.^ This con- 
nection is not invariable and exclusive — that is, there are marshy 
localities which are not malarious ; and there are malarious locali- 
ties which are not marshy — but there is no doubt, whatever, that 
it generally exists. The terms marsh miasm, and marsh fever 
have originated from this circumstance. 

Again, it is quite certain that the malarious poison may be 
transported by the atmosphere to a considerable distance from 
the place of its origin. M. Rigaud de l'lsle says: "About the 
end of 1810, 1 was at Civita Vecchia, in Italy. Passing through 
St. John's Place, which is a pretty regular square, I was shown 
one whole side where the inhabitants had been much afflicted with 
diseases occasioned by bad air, while those on the opposite side 
had almost escaped. What could be the cause of such an extra- 
ordinary difference between houses so near to one another ? Dr. 
Nucy, an intelligent physician, pointed out to us that the former 
faced the south, so as to receive directly the south-east winds, 
which arrive saturated with miasmata from the marshes on the 
coast." 1 A similar circumstance was observed in Philadelphia, 
in 1846. Dr. Wilcocks noticed that the occupants of houses 
exposed freely to the southerly winds, suffered much more gene- 
rally than those living on the same street, but more or less 
sheltered from these winds. 2 

dead ; but that the fevers of the country were much less extensively prevalent 
than during the previous year. He says also that the Ghetto in Rome — the Jews' 
quarter — is excessively filthy ; the narrow streets covered with decaying animal 
and vegetable matters ; but that it suffers much less from endemic fever than the 
more open, cleanly, and aristocratic neighborhood of the Vatican. — Trait e des 
Fievres, etc. Far E. M. Bailly, p. 125. 

1 Johnson on Trop. Climates, pp. 11 and 123. 

2 Am. Journ. Med. Sci., Jan., 1847. 



CAUSES. — MALARIA. 395 

Sir Gilbert Blane, in speaking of bilious remittent fever, says : 
"I have known a hundred yards in a road make a difference in 
the health of a ship at anchor, by her being under the lee of 
marshes in one situation, and not in another. It is difficult to 
ascertain how far the influence of vapors from woods and marshes 
extends; but there is reason to think that it is to a very small dis- 
tance. When the ships watered at Rock Fort, they found that 
if they anchored close to the shore, so as to smell the land air. 
the health of the men was affected; but upon removing two 
cables' length, no inconvenience was perceived." 1 

The effect of a wall of dense foliage in arresting the progress 
and preventing the diffusion of malaria has often been noticed. 
A striking instance is given by Dr. Wooten, of Alabama. I 
quote from Dr. Lewis's Medical History of Alabama. " Mr. 
P. E. had negro quarters situated on the first prairie elevation 
above the low grounds of a small creek, the fourth of a mile from 
the houses. This belt of low ground frequently overflowed, 
causing water to remain in holes over its entire breadth, on the 
subsidence of the stream; but it was well shaded by a dense 
foliage, the plantation lying on the prairie in the rear of the 
cabins. In the winters of 1842 and 1843, the trees between the 
houses and creek were cleared away ; and up to that time, 
some eight or ten years, the negroes living in this quarter had 
enjoyed uninterrupted health, a case of fever scarcely ever oc- 
curring. During the summer of 1843, the first after the forest 
had been cleared away, fever prevailed amongst the negroes with 
great violence, continuing until frost. The negro quarters were 
afterwards removed to the opposite side of the creek, about the 
same distance from it, but with an intervening growth of timber, 
and no fever has occurred on the place since." 2 

The latent period of the poison is quite indefinite ; it is some- 
times short, and sometimes long. Disease may follow its recep- 
tion into the system in the course of a day or two, or not until 
after the lapse of several months. Illustrations of this law are 
often furnished on a large scale by armies. John Hunter gives 
an instance which occurred in Jamaica. A fine healthy regiment, 
stationed in a malarious locality, suffered severely from fever: 

1 Dis. of Seamen, p. 221. 2 Med. His., etc., p. 17. 



396 PERIODICAL FEVER. 

they were removed to a healthy region, and first attacks con- 
tinued to occur for four months after the removal. Dr. Bancroft 
says many officers and soldiers, after their return from the expe- 
dition to Zealand, had primary attacks of intermittents, from six 
to nine months after their arrival in England. 1 Macculloch doubts 
the entire authenticity and conclusiveness of these reported in- 
stances of the action of malaria, at so long a period of time after 
exposure. 2 

The duration of the exposure to the poison, necessary for the 
production of the disease, is very short. 

The susceptibility of the system to the influence of malaria is 
lessened by long-continued exposure, but it is not destroyed. 
Malaria itself is destroyed, and its further evolution arrested by 
a temperature as low as the freezing point. 

1 Bancroft's Essay, p. 241. 

2 Macculloch on Marsh Fever, p. 24. 



397 



CHAPTER V. 

VARIETIES AND FORMS. 

ARTICLE I. 

BILIOUS REMITTENT FORM. 

I have already spoken of the subdivision of periodical fever 
into its three principal forms ; and it is in this chapter that I find 
a suitable place for stating the grounds of this subdivision, and 
for indicating the principal features of these three leading varie- 
ties. Bilious remittent fever has now been pretty fully described; 
and it is sufficient to say, here, that the principal point of dissem- 
blance between it and the pure intermittent form, consists in the 
continuance, in the former, of a considerable degree of febrile 
excitement, or of morbid action, during the intervals between the 
paroxysms or exacerbations of the disease. The several element 
of a paroxysm — the chill, the febrile reaction, and the perspira- 
tion — are also more distinctly marked in the intermittent than 
they are in the remittent variety; and they are repeated from day 
to day, or from period to period, with greater regularity and uni- 
formity. The remittent form is generally more inclined to run a 
determinate course, and then to cease, or to pass into the inter- 
mittent form than the latter. The fundamental pathological 
difference between the two varieties consists, probably, in the 
existence in remittent fever of more fixed and permanent local 
irritations than are to be found in intermittent fever. Bilious 
remittent fever itself can hardly be said to exhibit any very uni- 
form or well-marked varieties. Still, it is important to state that 
the fever of one season and one locality, frequently differs pretty 
widely from the fever of another season or another locality ; and 
similar differences may exist between the disease during one por- 
tion or another of the same season. In this respect, periodical 
fever only partakes of the mutability to which almost all diseases 



398 PERIODICAL FEVEE. 

— and especially such as are at all endemic or epidemic in their 
character — are subject. During certain seasons, and throughout 
certain regions, it is not only more or less violent and dangerous 
than it is at other times and in other places, but it assumes cer- 
tain peculiarities, more or less striking ; at one time there is a 
predominance of one set of symptoms — at another, of another 
set. Cleghorn says : " In July, when these fevers first break 
out, their type is commonly simple and regular ; their paroxysms 
are of short duration ; and after three, four, or five periods, they 
vanish of their own accord. As the season advances, the tertians 
become more dangerous and difficult, often terminating in malig- 
nant forms, especially if much rain without wind fall during the 
dog-days. About the time of the equinox they assume a sur- 
prising variety of forms, and very often counterfeit continual 
fevers, having long redoubled paroxysms. But as the winter 
draws near, their type becomes more simple, and though they 
prove tedious and obstinate in cold weather, yet they are more 
regular and less dangerous than in the summer." 1 Dr. Steward- 
son says: "In some seasons, the remissions are very well marked, 
and the disease very manageable ; whilst in others it is more pro- 
longed, the remissions more obscure, and the symptoms of the 
typhoid state more developed." 2 

ARTICLE II. 

CONGESTIVE FEVER. 

Sec. L — Names. There has been a good deal of confusion from 
the somewhat indefinite signification which has been attached to 
the term congestive fever, and from the loose manner in which it 
has been applied. The qualifying prefix, congestive — is generic 
in its character ; like the term typhoid, it is expressive of a patho- 
logical state or condition which may exist in different diseases. 
In this way most writers speak of congestive varieties or cases 
of cholera, of scarlatina, of yellow fever, and so on. They mean 
simply those forms of these diseases in which this pathological 
element, thus designated, predominates. The essential nature of 
the pathological condition itself is obscure. It is probably com- 

1 Rush's Cleghorn, p. 107. 2 Amer. Journ. Med. Sci., April, 1842. 



VARIETIES AND FORMS. ' 399 

plex ; and it may be more or less modified by its connection with 
individual diseases. In its simplest form, we generally under- 
stand by it an undue accumulation of blood in the vessels — 
usually the larger ones, and especially the veins — and the tissues 
of an organ or part. But in its connection with the grave forms 
of disease, of which I have just spoken, there seems to enter into 
its composition some unknown but profound modification of the 
great function of innervation. This function is the seat of a 
sudden and violent perversion ; and at the same moment, there 
is a like sudden and violent rush of the blood towards some one 
or more of the organs ; or a draining off of the serum, as hap- 
pens in epidemic cholera. This congestive state generally occurs 
during the early period of the diseases with which it is asso- 
ciated. 

The term congestive fever is now generally made use of, in the 
Western and Southern States, to designate the pernicious or 
malignant form of malarious fever. I can see no objection 
whatever to this use and application of the term ; it is only im- 
portant that its meaning should be determinately settled, and its 
application generally agreed upon. I would never attempt to 
introduce a new name for a common disease, so long as an old 
and familiar one could be found, not positively and seriously 
objectionable. 

Sec. II. — Type, and mode of attach. Congestive fever may 
belong either to the intermittent or to the remittent variety ; but 
to the former more frequently than to the latter. It may also 
assume any of the types of periodical fever ; but the quotidian 
and tertian are the most common. 

Sometimes the disease is fully developed, and clearly marked 
at the outset — the congestive seal is set upon it during its first 
paroxysm. At other times, and this seems to be more common, 
the first paroxysm does not differ very essentially from an ordi- 
nary attack of simple intermittent. Dr. Charles Parry, who has 
written a short and fragmentary, but most excellent paper upon 
the disease as it occurs in Indiana, says : " In the majority 
of cases, the symptoms of the first paroxysm are such as occur 
in an ordinary intermittent attack. One main peculiarity is an 
expression of intense apprehension, or terror, without experienc- 
ing it. Perhaps the face is paler, or more livid, than in common 



400 PERIODICAL FEVER. — CONGESTIVE FORM. 

cases. * * The first paroxysm attracts so little attention that, 
after it is over, the patient meeting a physician, or friend^ says 
that he feels as if he was about to be sick, not that he has been 
sick. The second paroxysm is always severe, not so much in the 
violence of the rigors, as in the extreme coldness, and in the 
approaching deathlike hue of the face and extremities." 1 

Sec. III. — Varieties; comatose. Congestive fever occurs 
under several well-marked and pretty distinct varieties, depend- 
ing, probably, upon the predominance of certain elements in its 
complex pathology. Torti divided the disease into seven varie- 
ties, to wit : 1. Choleric, or dysenteric ; 2. Subcruenta, or atra- 
biliaris; 3. Cardiac; 4. Diaphoretic; 5. Syncopalis; 6. Algid; 
7. Lethargic. Alibert makes no less than twenty varieties, 
elevating to this distinction every case marked by any peculiarity, 
accidental and unimportant as it may happen to be. The most 
common and important forms are the comatose, the delirious, the 
algid, and the gastric or g astro-enteric. It is necessary, in order 
to get a distinct and adequate idea of the disease, to give 
separate descriptions of these principal varieties. To aid me in 
doing this, I shall transfer to my pages a series of graphic 
delineations from the capital work of Maillot. 

" The name of the comatose variety," he says, "indicates its 
essential character. The coma varies from simple stupor to the 
most profound carus. The pulse is full, large, without hardness, 
ordinarily a little accelerated, sometimes slower than natural. 
The patient lies upon his back, the limbs as it were paralyzed; 
when the coma is not carried to its highest degree, if the 
skin is pinched, he utters a feeble and plaintive cry; there 
is often trismus ; still, liquids can generally be swallowed, 
although with considerable difficulty ; sometimes, however, they 
are rejected, either by a sudden and convulsive movement, or by 
a tranquil and prolonged expulsion. In somer are cases, instead 
of the usual resolution of the limbs, there are epileptiform move- 
ments, frothing at the mouth, and grinding of the teeth, truly 
frightful from their noise and rapidity. It is during the second 
paroxysm that the coma shows itself, in most cases nothing 
having occurred in the first indicative of its coming. If any- 

1 Amer. Journ, Med. Sci., July, 1843. 



VARIETIES AND FORMS. 401 

thing may foreshadow its appearance, it is a certain slowness of 
speech during the preceding apyrexia. But this indication is 
often fallacious, and its absence is no guarantee that the follow- 
ing paroxysm will not be comatose. Sometimes a case is coma- 
tose from the beginning ; at others it suddenly becomes so after 
a certain number of paroxysms, which had not affected the brain 
more than is usual in simple intermittents. Sometimes the coma 
reaches its highest degree suddenly, as by a single bound; at 
other times, and this is more common, the eye may follow the 
progress of its development. In the latter case, the physiogno- 
my of the patient assumes that expression of stupor characte- 
ristic of comatose affections, and so striking in these ; his replies 
are slow and unfinished ; the eyelids grow heavy and close. In 
certain cases, the coma is preceded by delirium. 

"After a period which it is impossible to determine beforehand, 
and which varies with a multitude of circumstances, if death is 
not occasioned by the violent cerebral congestion, a general sweat 
breaks out upon the surface, the patient executes some automatic 
movements, the eyelids are elevated, the eyes remain fixed and 
widely open, he remains a long time unconscious of what passes 
about him, and it is now, especially, that his look has that air of 
astonishment, which I have never seen so strongly marked in any 
other affection. He recovers by degrees the use of his senses ; 
sight, hearing, and speech return successively. Finally, all the 
functions resume their natural play, and in many cases after the 
paroxysm, especially if bloodletting has been practised, there 
does not remain even headache. 

" This variety is perhaps the most common. Most of the cases 
reported by Bailly at Rome belonged to it, and I have met with it 
more frequently than with any other form in Corsica, and Africa. 
It may be accompanied by visceral congestions or irritations in 
the chest or abdomen, but these complications are accidental." 

Sec. IV. — Delirious Variety. "When, during the second stage 
of a paroxysm, the headache becomes very severe, there is reason 
to apprehend the occurrence of delirium, especially if, during the 
preceding intermissions, this symptom has not entirely disappear- 
ed. The pulse is hard and accelerated ; the skin hotter and drier 
than in the comatose form ; the eyes are brilliant, the conjunctiva 
injected, and the face red and animated ; the patient cries, sings, 
26 



402 PERIODICAL FEVER. — CONGESTIVE FORM. 

and endeavors to escape ; the carotids and temporal arteries beat 
violently. This state of excitement commonly continues for 
several hours ; and then it is not unusual to see coma succeed to 
the delirium, so that, so far as the symptoms are concerned, the 
paroxysm may exhibit in the course of a few minutes the principal 
phenomena of the two stages of acute meningitis. Death fre- 
quently occurs suddenly, without the supervention of coma ; life 
is destroyed by a single shock. When a favorable crisis occurs, 
the skin becomes soft and sweaty, the pulse loses its hardness, and 
the delirium gradually ceases. There is some remaining head- 
ache, more frequently than in the comatose form. This variety is 
also very common. Nervous and irritable persons,~subject to de- 
pressing passions, are strongly predisposed to it ; it is often seen 
also in stout and robust men of a strongly marked sanguine tem- 
perament. I have never seen in the same paroxysm coma precede 
delirium." 

Sec. Y. — Algid Variety. " Algid fever is not generally, as has 
been said, a mere prolongation of the cold stage of a paroxysm. 
I have rarely seen it commence in this manner. There is between 
these two conditions a striking contrast even. In the first stage 
of a simple paroxysm, the sensation of cold is out of all propor- 
tion to the actual diminution of the temperature of the surface, 
while in algid fever the cold is not felt by the patient, even when 
the skin is icy. It is commonly during the period of reaction 
that the characteristic symptoms begin to show themselves ; often 
they supervene suddenly in the midst of a reaction which appeared 
to be open and frank. The pulse becomes slow, flags, and dis- 
appears ; the extremities, the face, and the trunk become succes- 
sively and rapidly cold; the abdomen alone preserves a slight 
degree of warmth, the skin feels as cold as marble; the tongue, 
whatever may have been its appearance at the commencement, 
becomes flat, white, moist, and cold ; there is no thirst ; and if the 
patient is induced to drink, the liquid is frequently returned as 
if by regurgitation ; the lips are colorless, the breath cold, and 
the voice broken ; the action of the heart is slow, feeble, and strug- 
gling, appreciable only by auscultation ; the mind is unimpaired, 
and the patient may seem to enjoy even this state of repose, espe- 
cially when it has succeeded to a violent fever ; his physiognomy 
is without mobility, the most absolute impassivity is stamped upon 



VARIETIES AND FORMS. 403 

his countenance; its expression is dead. It is only when vomit- 
ings and choleric discharges are added to this algid condition, that 
the eyes become sunken and glassy, and are surrounded by a blue 
circle ; and it is only when the respiration is carried on through 
the open mouth that the tongue becomes dry and dark colored. 
The march of this variety is very insidious ; there is no one per- 
haps, whose vigilance has not been deceived by it. If one is not 
familiar with this state of things, the kind of calm which follows 
the febrile excitement may easily be mistaken for a great ame- 
lioration, attributable perhaps to sanguineous depletions, and the 
mistake is revealed only by the sudden and unlooked for death 
of the patient." 1 

Bailly notices particularly the tranquil expression of the counte- 
nance in these cases. "I have already mentioned," he says, 
" that, in algid fevers, the patients pass from life to death with- 
out our being able to foresee this event ; we can hardly believe 
them to be sick even, either during the intermissions or the par- 
oxysms, especially in the early period of the latter." In the re- 
flections which follow the report of his thirty-seventh case, he 
says: " In this instance, especially, the color of the face was 
natural ; its expression was that of repose, of tranquillity ; only 
the muscles were a little tightened upon the bones of the face, 
but not like those of a phthisical patient, or of a person dying 
from acute gastritis ; it was rather the look of a man in full 
health who rests after excessive fatigue. Indeed, if this man 
had not been pointed out to me as one attacked with algid fever, 
I should not have paused to notice him, near as he was to the 
termination of his existence ; and when the paroxysm came on, 
his countenance, without becoming any more alarming in its ex- 
pression, approached that of a person just sinking into sleep. 
Nothing could be more striking than the contrast between this 
immobile face and the pain which he alleged to exist in the abdo- 
men. It seemed as if the torpor in which he was plunged had 
destroyed all the sympathies which usually exist between our 
organs, and as if the suffering abdomen had no power to act 
upon the physiognomy with which it was no longer in rela- 
tion." 2 

Whenever to a reaction, more or less decided, there suddenly 

1 Maillot. 2 Traite des Fievres Intermittentes. Par E. M. Bailly. p. 235. 



404 PERIODICAL FEVER. — CONGESTIVE FORM. 

succeeds feebleness of the pulse, with paleness of the tongue, and 
colorless lips, there should be no hesitation in regard to the case 
— it is one of algid fever. Temporizing here is death. .When 
the termination is to be favorable, the pulse becomes more dis- 
tinct ; the skin resumes its natural heat ; and there follows some- 
times, though rarely, an irritation of the brain, or digestive 
organs, requiring sanguineous depletion. The coldness dissipated, 
the- patient enters at once into full convalescence, as he does after 
a comatose or delirious paroxysm. I have never seen the pheno- 
mena constituting algid fever proceeding by distinct paroxysms ; 
they have hardly presented any appreciable remissions ; once 
established, they march steadily towards death, unless they are 
arrested." 1 The pulse, Dr. Charles Parry says, even from the 
beginning of the second paroxysm, is rapid, small, and thready ; 
sometimes hard and wiry, and sometimes irregular and intermit- 
ting. The skin is of a livid hue, and of a marble coldness ; and 
it is covered from head to foot with a cold, clammy, sticky sweat ; 
in some instances, this perspiration is confined to the face and 
neck. The hands are shrivelled like a washerwoman's, and the 
patient begs for cold drinks, and to be fanned. 2 

According to Maillot, the three preceding varieties constitute 
the immense majority of cases of pernicious intermittents. 
i 

Sec. VI. — Gfastro-enteric Variety. This form of congestive 
fever seems to be pretty common in our Western and Southern 
States. 

Dr. Charles Parry, in his description of it, says : " The vomit- 
ing and purging are almost incessant; the discharges are often 
mixed with blood, but not with bile. They have the appearance 
of water, in which a large portion of recently-killed beef has been 
washed. Sometimes, however, the proportion of blood is much 
greater, at times amounting almost to clear blood ; and from three 
to five or even twelve ounces at a discharge, with intervals of 
from ten to forty minutes. The discharges have but little odor, 
and there is but little abdominal pain or tenderness ; though the 
patient complains of a sense of weight and burning heat in the 
stomach. * * The thirst is most intense. The constant cry 

1 Traite cles Fievres Intermittentes. Par F. G. Maillot, pp. 28-36. 
* Amer. Journ. Med. Sci., July, 1843. 



VARIETIES AND FORMS. 405 

is for cold drinks, cold ice water ; and a very common exclamation 
is : '0, that I could lie in the river !' — l If I could only have a 
stream of cold water running through me!' "* 

I add the following, from Dr. Parry's general description. 
" The respiration," he says, " is often very peculiar. It consists 
of a deep-drawn double inspiration, or double sigh, with one ex- 
piration. This double breathing is seen in perhaps more than 
two-thirds of the cases ; it is a fatal symptom. It is seen very 
early in the second paroxysm, generally at the beginning, and 
continues to its close, either in the agony of death, or to the 
febrile reaction. 

" Restlessness is very great, the patient constantly tossing 
about from one side of the bed to the other, throwing about his 
arms and legs ; frequently endeavoring to get out of bed, and 
walking across the room, if permitted, only an hour or two before 
death. I have seen persons get out of bed, walk across the room, 
and stand in the doorway, hours after it was impossible to detect 
any pulse at the wrist, though the carotids could be felt plainly. 
Such is the intense desire of patients to get cold air, that they 
frequently express themselves determined to have it, at all haz- 
ards ; and, indeed, it frequently happens, even when nearly all 
the symptoms just enumerated are present, that the patient does 
not think there is much the matter with him, and wonders why 
he is kept in bed, and not suffered to go out. 

" The usual length of the fatal paroxysm is from three to six 
hours, though it is longer in some cases ; — the moribund symp- 
toms increasing, the pulse becoming more and more frequent, 
feeble, irregular, thready, and fluttering; the respiration pro- 
longed and sighing ; the skin cold and shrivelled, and covered 
with large drops of clammy perspiration." 1 

It is proper to mention that the preceding varieties may be 
more or less mixed up with each other, sometimes one of them 
preponderating, and sometimes another. It is hardly necessary 
to take any separate notice of the minor varieties — the cardiac, 
the icteric, the syncopalic, and so on. 

Amer. Journ. Med. Sci, July, 1843. J Ibid. 



406 PERIODICAL FEVER. — INTERMITTENT FORM. 

ARTICLE III. 

INTERMITTENT FEVER. 

The principal points of difference between the simple inter- 
mittent and the bilious remittent forms of periodical fever, have 
already been indicated. It only remains for me here to give a 
short general description of the former variety of the disease. 

The paroxysm of a regular and simple intermittent commences 
with the rigor, or chill. This is usually severe and strongly 
marked. The patient has an intense feeling of coldness ; his 
teeth chatter, and his whole body shivers with cold. The skin 
is pale and shrivelled, with a dark bluish or purplish tinge on the 
tip of the nose, the lips, and the extremities, and it is cold to the 
touch ; the features are pinched and shrunken ; the expression of 
the face is languid, listless, and uneasy ; there are frequent gap- 
ing and yawning ; a general feeling of weariness and fatigue, pains 
in the head, back, and limbs ; sighing respiration, oppression of 
the prsecordia ; a small and frequent pulse ; and the mind is 
feeble and depressed. Such are the ordinary and more obvious 
phenomena constituting the cold fit. The urine is generally 
abundant and limpid. 

After a period of time, varying from fifteen or twenty minutes 
to three or four hours, the average length being an hour or so, 
the first stage passes gradually into the second. The sensation 
of coldness yields to a feeling of morbid heat ; the skin is full and 
injected, and is hot to the touch ; the face loses its languid ex- 
pression, and becomes animated and flushed ; the prsecordial op- 
pression is sometimes removed or diminished, but not always ; 
there are less languor and depression ; the local pains, instead of 
diminishing, are increased in severity ; the pulse becomes full and 
strong; there is increased thirst; and the urine is now scanty and 
high colored. 

This second or hot stage continues from one to fifteen or eigh- 
teen hours, and then gives way to the third, or sweating stage, 
which completes the paroxysm. As the surface becomes moist, 
the febrile perturbation subsides ; — the pulse is slower and softer ; 
the expression of the face tranquil ; the local pains and the other 
uneasy sensations disappear ; the urine deposits a reddish sedi- 



VARIETIES AND FORMS. 407 

merit, and there is a general and delightful feeling of relief and 
of restoration to health. 

The period between the termination of this and the commence- 
ment of the next paroxysm constitutes the intermission. In many 
cases, where the disease is quite simple, and where there are pro- 
bably no considerable local irritations or congestions, this apy- 
rexial period seems to be one of entire freedom from disease. The 
strength, the appetite, and the cheerfulness of the patient are 
restored ; all his functions, animal and organic, seem to have 
resumed their healthy activity. In other instances, however, 
there are still remaining, throughout the entire period of inter- 
mission, evidences more or less obvious and serious, of a disor- 
dered state of the system. 

The entire duration of the paroxysm, as well as that of its 
several stages, varies very greatly in different cases. It ranges 
from a few hours to eighteen or twenty. 



408 



CHAPTER VI. 

DURATION AND MARCH. 

Sec. I. — Duration. The average duration of the common form 
of remittent fever seems to be about two weeks, perhaps a very 
little longer. Of eleven cases treated in the Pennsylvania Hos- 
pital, by Dr. Gerhard, the mean duration was fourteen days and 
a half; of fifty-four cases treated in the same institution, and re- 
ported by Dr. Stewardson, the mean duration was about fifteen 



The duration of the other varieties is so various and indefinite, 
and so much influenced by circumstances, that it is not easy to 
establish any positive averages. Congestive fever terminates 
speedily, in most cases, either in recovery or death. Dr. Charles 
Parry says: " The general duration of this disease is from six to 
nine days, in recovering so as to walk about ; in fatal cases, from 
two to three days, death usually occurring in the second or third 
paroxysm, hardly ever in the first." 1 

The duration of the simple intermittent form is altogether in- 
definite. It may consist of only one or two paroxysms; or it may 
be continued, with more or less regularity, for several weeks, and 
even for several months. 

Sec. II. — March. The types of periodical fever have been 
already sufficiently treated of in the chapter on the symptoms of 
the disease. The march of the fever differs considerably in the 
different forms of the disease. The progress of remittent fever is 
generally pretty regular — the disease gradually increasing in 
severity until it reaches its height or acme, and then passing 
into convalescence. Cleghorn seems to have studied this subject 
with great care, and he makes the following observations in regard 
to it : "As the fever advances to its height, the coldness and 

1 Amer. Journ. Med. Sci., July, 1843. 



DURATION AND MARCH. 409 

shivering which usher in the paroxysms become less, or entirely 
imperceptible; in which case a cholera morbus, or acute pains 
in the back or' limbs, supply their place. In the mean time, the 
paroxysms themselves become longer, and bring on more formi- 
dable symptoms, such as headaches, raving, sopors, apoplectic 
fits, bleeding at the nose, cough, difficulty of breathing, palpitation 
of the heart, irregularity of the pulse, sickness and anxiety, pain 
about the upper orifice of the stomach, and so on. Besides, it 
often happens, during the second, third, fourth, or fifth period, 
that the tertian becomes double, though at first it was simple; or 
if it was double from the beginning, the weaker fit continues 
without any intermission, till the stronger comes on, and both 
being blended together, the disease puts on the appearance of a 
semi-tertian having one very long fit, with a short interval every 
forty-eight hours. It must likewise be observed that, in the pro- 
gress of the fever, the regular order of the periods is frequently 
disturbed by the paroxysms changing their hour of invasion, and 
attacking unawares, without any previous cold. After this man- 
ner, these proteiform distempers continue to vary their shape in 
every period, and to produce longer, more severe, or more fre- 
quent paroxysms till they arrive at their height; about which time 
the fits and intervals are often so confused that they are scarcely 
to be distinguished ; nevertheless, if death be not speedily the 
consequence of this confusion, they commonly again put on a 
more simple or regular form, and, after one or more slight parox- 
ysms, go away of their own accord. Those fevers which come 
to their height in the third period, terminate in the fourth or fifth 
period; those which come to their height in the fourth period, ter- 
minate in the fifth or sixth ; and those which come to their height 
in the fifth period, terminate in the sixth or seventh. "When the 
most vehement paroxysms happen on the odd days, the crises will 
be on the odd days : when they happen on the even days, the 
great changes of the distemper will likewise be on the even days. 
If the fever increases* to the seventh period, it probably will not 
cease before the ninth; but it rarely happens that remitting tertians 
run out to so great a length. Yet I have seen every year a few 
of the continual kind, which began with great mildness, and, in- 
creasing by slow degrees, broke out violently in the third or fourth 
week, and soon after ended inintermittents; though some of them 



410 PEKIODICAL FEVER. 

have continued without any considerable intervals for six or seven 
weeks. But it is much more common to meet with tertians, which 
set out furiously, with severe subintrant double paroxysms; so 
that for some days they have little or no interval. On the third 
or fifth day a profuse sweat commonly brings on an intermission ; 
and afterwards the disease assumes the type of a double intermit- 
ting tertian, or of a semi-tertian. Such fevers I have frequently 
observed to terminate spontaneously on the seventh, ninth, and 
eleventh days ; and, for the most part, they are less to be feared 
than those which begin deceitfully in the shape of a slight double 
or simple tertian. For, however mild and insignificant these in- 
termittents may at first £eem to be, we are never to trust appear- 
ances till they have performed three or four revolutions." 1 

The progress of the malignant form of the disease is more 
irregular and uncertain. 

Senac thus speaks of the sudden and great changes^ so striking 
in this last variety: " It may be thought singular in these dis- 
eases that sometimes, from so slight a beginning, the danger should 
become so urgent and threatening in the course of a few days. 
But it is a problem no less difficult to solve, how a cause which 
so disorders the brain, and so oppresses the lungs can, of its own 
accord, give the system a temporary respite, or cease for a time 
to act. Thus, after the third or fourth day, the action of this 
cause is suspended, and for a day or more the patients seem free 
from disease. Other maladies do not pursue such a course ; in 
them the affected parts recover only by degrees ; and after they 
have recovered, or appear to have recovered in the space of a day 
or two, the life of the patient is seldom brought into danger 
again by a sudden return of the disease ; at least this is not gene- 
rally the case, as it is in malignant intermittents. * * * Hence it 
appears that these terrible symptoms may arise from some wan- 
dering stimulus, which flies off and returns, or acts and lies dor- 
mant, alternately ; and that they are sometimes more alarming in 
appearance than dangerous in reality." 2 Bailly says : u This 
sudden transition from a state of imminent danger to apparent 
safety is especially characteristic of comatose intermittents. In 
the other varieties of pernicious fever, there is not so striking a 
difference between the different stages of a paroxysm. * * * A 

1 Rush's Cleghorn, p. 95, et seq. 2 Caldwell's Senac, p. 118. 



CRITICAL DAYS. — RELAPSES. — SEQUELS. 411 

finger compresses the brain — the patient sleeps; if the pressure 
is light, everything returns promptly to its natural condition; if 
the pressure is strong, it kills on the spot." 1 

Sec. III. — Critical Days. It is the proper place here to say 
a word or two about the existence of what have been called 
critical days — days upon which, more than upon others, the dis- 
ease has a tendency to terminate either in recovery or death. 
There is no doubt, whatever, that the old doctrine upon this sub- 
ject is the true one, and the disputes which have arisen about it 
have originated in the circumstance that physicians have en- 
deavored to apply it to the family of continued fevers, a class of 
diseases in regard to which it utterly fails. It follows almost 
necessarily that a disease, marked as periodical fever frequently 
is, by a regular tertian revolution, should be liable to particular 
changes, either for better or for worse, on particular days ; and 
this is the whole substance of the doctrine of critical days. 

Sec. IV. — Relapses. Periodical fever, more than any other 
form of acute disease, is liable to return, and to. repeat itself, 
again and again, in the same subject. When the malarious poi- 
son has been once received into the system, the action of slight 
occasional causes will often continue, for a long time, to bring 
back the disease. 

Dr. Charles Parry says of congestive fever: "Once having 
had an attack does not exclude the possibility of having another 
the same season, although a second attack is rare. I had one 
patient who had two attacks one season ; and I had one patient 
who had an attack in three successive summers." 2 

Sec. V. — Sequelx. Periodical fever, especially if it has been 
often repeated, or long continued, very frequently leaves behind 
it serious and profound alterations of some of the organs, or 
more or less grave disturbances of their functions. The princi- 
pal of these I shall here enumerate. The first to be mentioned 
consist of various chronic alterations of the liver and spleen, 
especially the latter. These organs become enlarged, indurated, 
or both ; and their intimate structure, in many instances, vari- 

1 Traite, etc., p. 171. 2 Am. Journ. of Med. Sci., July, 1813. 



412 PERIODICAL FEVER. 

ously changed. From the time of Hippocrates to the present 
day, the frequency of these chronic organic alterations has 
attracted the notice of all observers. When they become invet- 
erate and extensive, from long exposure to the malarious poison, 
and from repeated attacks of fever, they generally entail upon 
the patient gradually increasing debility, dropsical accumulations, 
a broken-down constitution, and finally death. In many in- 
stances, however, it is surprising to what an extent, and for how 
long a period, the system will bear up against these inroads. 
"I have often seen these subjects," says Bailly, "arriving at the 
hospital in Rome, with the abdomen hard as a stone, the spleen 
occupying the whole anterior part of the cavity. A few inter- 
mittent paroxysms constituting the only disease which brought 
them to the hospital, they were treated like the other patients ; 
the paroxysms were arrested by quinine, and at the end of two 
or three weeks, they departed to resume their occupations, cured 
of the fever, but with the abdomen as hard as ever." Maillot 
says that he has often noticed, amongst the shepherds of Corsica, 
stout and robust men, engaged in rough out-door occupations, 
with the abdomen enormously distended in consequence of these 
alterations. 1 

The notion has been extensively prevalent, that these visceral 
obstructions are the result, not of the disease itself, but of the 
bark and its preparations, which are given for its cure. It is 
hardly necessary for me to say that there is no foundation what- 
ever for this opinion. 

The dropsical effusions, and especially the ascites, which so 
frequently accompany the latter stages of these cases, are, for 
the most part, the result of the changes in the state of the liver 
and spleen, and of the watery condition of the blood. 

In hot climates and seasons, long-continued cases of periodical 
fever are pretty frequently followed by chronic dysentery and 
diarrhoea. Maillot says that these consecutive affections are 
almost constantly without fever ; there is little or no pain in the 
bowels ; the discharges are serous, mucous, or sanguinolent, and 
generally abundant and frequent, but sometimes scanty. There 
is rapid emaciation ; the skin is of an earthy hue, dry and fur- 

1 Traite des Fievres Intermittentes, p. 246. 



SEQUELAE. 413 

furaceous. Of thirty cases, occurring in the French military 
hospital in Algiers, fourteen terminated fatally. 1 

Dr. Finley, in a paper on the autumnal fever of Georgia, says: 
" A severe attack of the disease always leaves the system very 
much deranged. All the secretions are impaired ; the skin is dry 
and harsh ; the biliary secretion alternately vitiated and defec- 
tive ; the bowels constipated." 2 

Another pretty common consequence of this disease consists in 
different disturbances and perversions of the nervous system. 
Amongst these are — neuralgic pains ; headache; muscular weak- 
ness; partial and incomplete paralysis, usually of the lower 
limbs ; and impaired activity, or derangement, of the mind. 
Scnac says, in speaking of the headache : " Patients sometimes 
declare that the head feels as if it were cleft asunder in the mid- 
dle." Dr. Mosely says : " Imbecility of mind, as well as of body, 
is a common consequence of long and obstinate disorders in 
hot climates ; and I have frequently observed that the mind has 
been greatly impaired after irregular and harassing intermittents ; 
and sometimes a temporary insanity has ensued. This must have 
been also observed by others; but as far as I know, no person 
except Sydenham, who was the first that noticed it, has men- 
tioned it as occurring in practice. He says he has often found, 
when the patients had been extremely debilitated by long con- 
tinuance of the disease, the doubling of the fits, and repeated 
evacuations, that they have been seized with a madness, when 
they began to recover, which went off proportionally as they 
gathered strength; but that, sometimes, from injudicious evacua- 
tions only, it has degenerated into a miserable kind of folly for 
life." 3 Maillot mentions amongst the effects of the disease no- 
ticed amongst the French soldiers in Africa, extreme debility 
durino* convalescence, especially in the hot season; and trembling 
of the muscles, like slight chorea, or like the paralysis of the 
insane. He thinks that neither the type of the fever, nor the in- 
tensity of the local irritations, has much influence in the produc- 
tion of these effects. 4 Macculloch enumerates a great variety of 

1 Traite des Fievres Intermittentes, p. 244. 

2 West. Med. and Phys. Journ., vol. iii. p. 179. 

3 Mosely on Trop. Dis., p. 189. 
* Maillot on Inter., p. 250. 



414 PERIODICAL FEVER. 

nervous disturbances and perversions, the result of repeated 
attacks of marsh fever. 

Another common consequence of long-continued periodical 
fever, or of the chronic lesions to which it gives rise, is an anemic 
condition of the system. The blood loses its healthy proportion 
of globules; the gums, lips, and tongue lose their fresh color; 
and the skin is sallow and pale. 



415 



CHAPTER VII. 

MORTALITY AND PROGNOSIS. 

The danger attending periodical fever depends very much 
upon the form which the disease assumes. The purely intermit- 
tent and benign variety is never fatal, without some accidental 
complication. It often entails upon its subjects chronic visceral 
alterations, which impair the vigor of the system, and which often 
shorten life, but it is never directly and immediately fatal. The 
ordinary remittent form is more grave in its character, but still, 
in a very large proportion of instances, it terminates favorably. 
Of sixty-three cases of periodical fever admitted to the Pennsyl- 
vania Hospital, in 1838, 1839, and 1840, six terminated fatally ; 
but three of these belonged to the congestive form, and were 
received only a short time before death ; and in one other case 
the disease had been greatly aggravated by improper treatment. 1 
Dr. Wilcocks treated one hundred and seventy-one cases of re- 
mittent and intermittent fever, in Philadelphia, in 1846, and they 
all recovered. He does not state the proportion of cases of the 
two forms. 

At the hospital of Montluel, of thirteen hundred and fifty-two 
cases, treated between June, 1822, and December, 1826, one 
hundred and thirteen terminated fatally. At the military hospital 
of Bona, in Africa, in twenty-two thousand three hundred and 
thirty admissions between April, 1832, and March, 1835, there 
were two thousand five hundred and thirteen deaths, nearly one 
in nine. 2 

Other things being equal, and as a general rule, the gravity and 
fatality of periodical fever increase as we approach the tropics. 
"Thus," say MM. Fournier and Begin, "if we examine the en- 
demic diseases of the principal malarious countries, we shall see 

1 Am. Journ. of Med. Sci., April, 1842. 

2 Traite, etc. Par F. C. Maillot, p. 276. 



416 PEKIODICAL FEVER. 

in Holland, intermittent fevers attacking great numbers of sub- 
jects, but generally following a slow march, and giving the phy- 
sician sufficient time to combat them. In Hungary, these fevers 
are more frequently remittent, and complicated with dysentery. 
The fevers of Italy, in the neighborhood of the Pontine Marshes, 
have short intermissions, and are frequently complicated with 
ataxic phenomena." 1 

In regard to congestive fever, Maillot makes the following in- 
teresting observations and statements. "I do not know," he 
says, " how the opinion has established itself that 'pernicious 
intermittents are readily curable, and that art is almost certain 
to triumph over them. But, ever since Lautter said that in these 
diseases the physician is the arbiter of life and death, writers 
have spoken very lightly of the prognosis of these terrible affec- 
tions ; they have proclaimed their treatment as the. triumph of 
medicine. Certainly, it is a beautiful thing to snatch from an 
imminent death, to rescue almost from the tomb, a man stricken 
with a pernicious paroxysm ; the danger was so urgent that one 
has hardly indulged a hope of his patient's recovery, when he is 
already cured; but, deceived by the eclat of similar successes, 
we have been carried away by our enthusiasm, and have refused 
to believe in the possibility of reverses, for it has been almost 
alleged that we had reached mathematical certainty in the treat- 
ment of these diseases. But to this enthusiasm, in which we 
ourselves for a long time participated — to these sanguine antici- 
pations which we should still rejoice to indulge, let us oppose the 
rigorous impartiality of positive statistical results. In eight 
hundred and eighty-six cases of pernicious fever, observed in 
1818 and 1819, at the hospitals of the Holy Spirit, and Saint 
John in Lateran, at Rome, there were five hundred and forty-five 
recoveries and three hundred and forty-one deaths — one death 
in two and a quarter. In five hundred and eighty-one cases of 
periodical fever, observed by M. Nepple, fourteen belonged to the 
pernicious form ; six of these terminated fatally. Antonini and 
Monard, in thirty-nine comatose or apoplectic cases, had nine 
deaths; in eighty-six encephalitic cases, they had only eight 
deaths — unquestionably the most favorable result on record, if 
they include in this category only cases of the delirious variety. 

1 Diet, des Sci. Med., art. Marais. 



MORTALITY AND PROGNOSIS. 417 

The following is the result of my own experience. I have notes 
of one hundred and eighty-six cases, belonging to the comatose, 
delirious, and algid varieties, occurring between the first of June, 
1834, and the first of March, 1835, thirty-eight of which, about 
one-fifth, terminated fatally. Seventy-seven comatose cases fur- 
nished fourteen deaths, one in five and a half; sixty-one delirious 
cases furnished twelve deaths, one in five ; and forty-eight algid 
cases furnished twelve deaths, one in four. The mortality varied 
with the type in the following manner. Sixty cases of the quoti- 
dian type furnished fifteen deaths, one in four ; thirty of these 
were of the comatose form, and gave six deaths, one in five ; 
twenty-one were of the delirious form, and gave five deaths, one 
in four ; and nine were of the algid form, and gave two deaths, one 
in four and a half. Twenty-seven cases of the tertian type fur- 
nished six deaths, one in six, nearly; nine of these were of the 
comatose form, and gave two deaths, one in four and a half; four- 
teen were of the delirious form, and gave three deaths, one in five, 
nearly ; four were of the algid form, and gave one death, one in 
four. Ninety-nine cases of the remittent and pseudo-continued 
type, furnished nineteen deaths, one in five, nearly ; thirty-eight 
of these were of the comatose form, and gave six deaths, one in 
six, nearly ; twenty-six were of the delirious form, and gave four 
deaths, one in six, nearly ; thirty-five were of the algid form, and 
gave nine deaths, one in four. 

"Such is the mean rate of mortality that has attended perni- 
cious fevers at Bona. In localities where the malarious poison 
is less powerful, it is probable that more favorable results may 
be looked for ; but otherwise, I have reason to believe, from the 
researches which I have made, that proportions much more 
encouraging than those just indicated have never been obtained, 
unless it may have been accidentally. 

"If now we endeavor to ascertain the modes in which death 
takes place in periodical fever, we shall find that in the acute 
forms, the patient is either carried off suddenly, during a parox- 
ysm, or that the paroxysms are prolonged and run into each other, 
the visceral congestions becoming fixed and being followed by 
inflammation, and complicated frequently with a typhoid condi- 
tion. When death does not happen in either of the foregoing 
modes ; when relapses have followed each other in rapid succes- 
sion; especially when the disease has been neglected, and the 
27 



418 PERIODICAL FEVER. 

irritations feebly combated, there then supervene chronic affec- 
tions of the digestive tube, engorgements of the abdominal viscera, 
intractable diarrhoeas, dropsical effusions, etc. 

"Amongst three thousand seven hundred and sixty-five patients 
received into the military hospitals of Bona, in the space of four- 
teen months, there were one hundred and thirty-five deaths, 
occurring in the following modes. Fifteen hundred and eighty-two 
cases of the quotidian type furnished forty deaths, one in forty, 
nearly ; of these patients, eight died in a delirious paroxysm ; 
eight, in a comatose paroxysm ; three, in an algid paroxysm ; one, 
with jaundice ; five, in a typhoid condition ; thirteen, ivith chronic 
diarrhoea or dysentery ; one, with acute dysentery ; and one, ane- 
mic. Seven hundred and thirty cases of the tertian type furnished 
twelve deaths, one in sixty-one, nearly ; of these patients, three 
died in a delirious paroxysm ; two, in a comatose paroxysm ; one, 
in an algid paroxysm ; three, with chronic diarrhoea or dysentery ; 
and one each with chronic bronchitis, chronic pneumonia, and 
marasmus. The quartan type furnished no death. One double 
tertian had a fatal issue, after six weeks' duration. Seventy-nine 
cases of the remittent type furnished two deaths, one in a delirious 
and one in a comatose paroxysm. Thirteen hundred and thirty- 
two cases of a continued or pseudo-continued type furnished eighty 
deaths, one in sixteen and a half, nearly ; of these patients, five 
died in a delirious paroxysm; seven, in a comatose paroxysm ; ten, 
in an algid paroxysm ; thirty-one, with chronic diarrhoea or dysen- 
tery ; three, with acute dysentery ; three, with typhoid affections ; 
three, with chronic pneumonia ; six, with acute follicular colitis ; 
two, with chronic bronchitis : two, with chronic affections of the 
heart ; and one each, with acute gastro-colitis, encephalitis, ence- 
phalic irritation followed by paralysis, apoplexy, acute bronchitis, 
acute carditis, and marasmus. 

" To sum up these details, death took place during the parox- 
ysm, in fifty-one cases ; in a typhoid condition, in eight cases; from 
diseases such as occur in non-malarious regions, in fifteen cases ; 
from chronic affections, in sixty-one cases, forty-seven of which 
were chronic diarrhoeas or dysenteries." 1 

In another place, Maillot says : " The prognosis in pernicious 
fever is always very grave. The principal varieties — the deliri- 
ous, the comatose, and the algid — give nearly the same mortality. 

1 Traite des Fievres Intermittentes. Par F. G. Maillot, p. 277, et seq. 



MORTALITY AND PROGNOSIS. 419 

When, notwithstanding large sanguineous depletions, the coma 
continues profound, and the pulse remains strong and full, although 
the patient may be bathed in sweat, we have reason to fear a fatal 
issue. Death may be equally apprehended, if the persistence of 
the coma is accompanied by a rapid, feeble, small and vibrating 
pulse. There are comatose cases where the trismus is so strong 
that the patient is unable to swallow ; or where, on the other hano\ 
the rectum will not retain any injection : the prognosis is here 
very unfavorable : there are no means of administering the sul- 
phate of quinine but by the skin. The delirious variety isolates 
itself less frequently than the comatose in the nervous system ; 
it is more frequently associated with symptoms of acute abdo- 
minal inflammation ; if with this there is vomiting, so that the 
febrifuges are rejected, the danger is very great. When the 
delirium persists, and the pulse at the same time becomes small 
and feeble, and the skin is covered with a cold, clammy sweat, 
death is imminent. In the algid variety, the prognosis varies with 
the intensity of the morbid phenomena. If the pulse entirely 
disappears, the danger is extreme. This suspension of the cir- 
culation, if it is continued for some time, is certainly followed by 
death. If the pulse can be still felt, although only at consider- 
able intervals, whatever may be the degree of coldness, we may 
indulge hope. When algid fever is accompanied by choleric 
vomiting and purging ; when the face and extremities are blue, 
the breath cold, and the voice broken and sepulchral, death is 
almost inevitable. Vomiting without effort, as if by regurgitation, 
in the course of algid fever, with a moist, white, cold, and flat 
tongue is always of fatal augury ; it has appeared to me to be 
connected with extensive and chronic softening of the mucous 
membrane of the stomach." 1 Maillot thinks that in most cases 
of fatal pernicious fever, there existed some chronic lesion before 
the access of the disease. Dr. Charles Parry, in his paper on the 
congestive fever of central Indiana, says : " Without treatment, 
or with the usual treatment of bilious fever, which is little better 
than none in this disease, probably three-fourths of the cases ter- 
minate fatally. But with a special treatment, not more than one 
in eight." 2 

1 Traite des Fievres Intermittentes. Par F. G. Maillot, p. 343. 

2 Am. Journ. Med. Sci., July, 1843. 



420 PERIODICAL FEVER. 

"In the mean time," says Cleghorn, "it is to be remem- 
bered that as in all acute diseases, so particularly in these fraudu- 
lent, deceitful fevers, the presages either of death or recovery are 
not always certain and infallible ; it frequently happening that 
those who have laid in the paroxysm for hours together, with few 
or no signs of life, have at length recovered as it were from the 
jaws of death, and asked for some uncommon sort of food, to the 
great surprise of everybody about them ; on the other hand, the 
fit anticipating sometimes brings on death before the time it was 
indicated." 1 

"Can we determine in advance," says Maillot, "whether a 
simple intermittent will or will not become pernicious in its cha- 
racter ? I think not. Frequently, we cannot do this even at the 
commencement of a pernicious paroxysm. Without doubt we 
have reason to apprehend the approach of this perilous form of 
the disease, whenever any of the visceral irritations are intense 
— whenever the symptoms of gastro-enteritis, or encephalitis, are 
strongly marked ; but this rule has many exceptions, and I have 
often seen the most pernicious paroxysm succeed, without any 
premonition, to those of the simplest character." 2 

The prognosis is thus summed up by Cleghorn. "If the 
paroxysms are not attended with acute pains in the viscera, and 
do not last above twelve hours ; if they decline with plentiful 
warm sweats, and leave the intervals tolerably free ; if the pa- 
tient bears the distemper well, and begins to have an appetite for 
victuals ; if small pustules break out in the inside of the mouth, 
or scabs about the lips ; if the urine has recovered its natural 
complexion, or is cloudy and turbid, or lets fall a white or a pale 
red sediment ; — I say if all these signs concur about the third or 
fourth period, we may safely prognosticate a speedy recovery. 
On the other hand it announces danger when, about this time of 
the disease, the paroxysms are long and protracted ; or are ac- 
companied with an obstinate delirium, an intense coma, great 
anxiety, and pain in the loins, or about the upper orifice of the 
stomach ; when the patient has an utter aversion to food, and 
even in the intervals is so feeble, and attended with such a swim- 
ming in the head, that he can scarcely walk about ; when the hypo- 
chondria and epigastric region are swelled, hard, and painful to 

1 Rush's Cleghorn, p. 103. 2 Traite des Fievres Intermittentes, p. 338. 



MORTALITY AND PROGNOSIS. 421 

the touch ; when numerous blotches, like the stinging of nettles, 
frequently break out on the skin ; when the urine continues thin, 
clear, high colored, or covered with an ash-colored membrane, like 
a cobweb ; and lastly it announces danger, when larger evacua- 
tions come on than the strength can well bear, such as vomiting, 
purging, bleeding of the nose, colliquative sweats, or the like. 
For fevers with these appearances sometimes are immediately 
changed into mortal dysenteries ; sometimes they become con- 
tinual tertians, and run out to a great length ; but, for the most 
part, they preserve the form of remitting or intermitting fevers, 
and daily growing stronger, prove very dangerous about the sixth 
or seventh period. 

" Those fevers are most to be dreaded, whose violence is great- 
est on the even days ; and if the paroxysm stops on the third, 
fifth, or seventh day, but continues on the fourth, sixth, or eighth 
day, we must be upon our guard, lest a sudden storm should suc- 
ceed this treacherous intermission. 1 * * Nor is there only a pos- 
sibility, in many cases, of foretelling the day, but likewise the 
hour, on which the patient will expire ; for that stage of the pa- 
roxysm which he usually got over with the most difficulty will 
most probably in the end prove fatal. I have seen some expire 
in what may be called the first stage of the paroxysm ; the skin 
being chilled, and wet with cold sweats, their pulse small and ir- 
regular, and their senses entire to the very last. But the great- 
est numbers are hurried off in the height of the hot fit, stupefied, 
senseless, the breathing short and laborious, and the skin covered 
with a burning fiery sweat." 2 

Maillot observes, that in the delirious variety of pernicious in- 
termittents, there is frequently a strong apprehension of approach- 
ing death, and that this feeling is always a fatal augury. 3 

Dr. Charles Parry observes, that the plethoric, young, and 
robust, are most apt to die ; and that the age, in a majority of 
fatal cases, is from twenty-five to thirty-five. 

The return of the paroxysm, in all the forms of periodical 
fever, at an earlier and earlier period of the day, is a favorable 
indication ; its appearance at a later and later period is unfavor- 
able. 

1 Rush's Cleghorn, p. 98. 2 Ibid., p. 103. 

8 Traite des Fievres Intermittentes, p. 58. 



422 



CHAPTER VIII. 

DIAGNOSIS. 

The diagnosis of well-marked and uncomplicated cases of 
nearly all diseases is a matter, in the actual state of medical 
science, not often attended with any considerable difficulty. This 
is true of periodical fever. Under such circumstances, its several 
forms can be distinguished from each other, and from all other 
diseases, with great facility and certainty. The mark which is 
set upon these diseases by their family seal of periodicity separates 
them broadly and widely from nearly all other affections. It 
sometimes happens, however, that this seal becomes so blurred 
and indistinct, or is so nearly obliterated, as to lose much of its 
value as a diagnostic and distinctive indication, and we are 
obliged to resort to other and collateral sources for the true 
character of the disease. This happens most frequently under 
the following circumstances. In the warmer malarious regions, 
and during the prevalence of the graver forms of periodical fever, 
the bilious remittent variety, especially, frequently loses to a great 
extent its periodical or remittent character, and assumes more or 
less entirely a continued form. This modification usually takes 
place during the latter period of prolonged cases, and under these 
circumstances the resemblance between the disease and continued 
fever becomes very close; and this resemblance is frequently 
increased by the presence of typhoid phenomena — great debility, 
feeble pulse, dry and brown tongue, tympanitic abdomen, diar- 
rhoea, and so on. It would be foolish to deny the difficulty, 
under such circumstances, of always distinguishing between this 
modification of remittent fever, and continued fever of the typhoid 
character. The resemblance here is so striking, that the opinion 
has extensively prevailed in this country, and still continues to 
prevail, that bilious remittent fever is not unfrequently changed 
in its progress into continued typhoid fever. The mistake here 
is that very common one of confounding the typhoid state or 



DIAGNOSIS. 423 

condition present in many diseases, with specific typhoid fever. 
But, notwithstanding this resemblance, and the difficulty which I 
have admitted, a careful study of the previous history of these 
cases, and of all the circumstances attending them, will generally 
enable us to come to a pretty positive conclusion, and to establish 
a pretty certain diagnosis. We shall almost always find that 
during the first week or two of the disease, its remittent cha- 
racter was so decided as to remove all uncertainty as to its true 
nature. We shall find, further, in most cases, certain differences 
between the actual condition of the patient and the phenomena 
of typhoid fever. The rose-colored eruption will be wanting ; 
the low, muttering, and continuous delirium, with twitching of 
the tendons, and picking at imaginary objects, so common in 
grave cases of continued fever, will at least very rarely be as 
prominent and striking ; and the periodical tendency, masked 
and crippled as it is by the complication of local congestions and 
inflammations, will still, if closely watched for, frequently manifest 
its presence, by various slight and irregular but sudden changes, 
such as are not often met with in continued fever. 

Dr. Stewardson says, that when the disease is prolonged, the 
remissions obscure, and the typhoid state present, the distinction 
between bilious remittent and typhoid fever may be rendered 
somewhat difficult ; but that generally errors of diagnosis might 
be avoided by greater attention, and a more intimate acquaintance 
with the essential characters of the two diseases. 1 

During the paroxysm of the unmixed comatose or delirious 
form of congestive fever, the condition of the patient may be 
almost the same as in some local diseases of the brain. The 
history and the collateral circumstances of the case will generally 
be sufficient to remove all doubts as to its true nature. 

"If, as it frequently happens in the hospitals," says Maillot, 
" we had no previous knowledge of a patient, whom we find with 
coma or delirium, we might suppose the case to be one of acute 
meningitis, and resort at once to bloodletting, which, indeed, 
would be proper in either case. But the influence of the treat- 
ment upon the march of the symptoms would soon dissipate all 
doubt as to the nature of the affection. If it is a pernicious 
intermittent, and death does not take place during the paroxysm, 

1 Am. Journ. Med. Sci., April, 1842. 



424 PERIODICAL FEVER. 

the coma or the delirium will disappear in a few hours, the skin 
will cover itself with an abundant sweat, the pulse will become 
apyrectic, and there will remain little or nothing of the condition, 
which, a few minutes before, so seriously endangered life. If, 
especially, all this happens in a malarious region, or during the 
prevalence of intermittent fevers, it is impossible to mistake a 
pernicious paroxysm for any other disease. For it is not in this 
manner that acute continued affections proceed. Look at a me- 
ningitis. As it is by degrees that it arrives at its highest point 
of intensity ; as it is only after having continued for several days 
that the headache gives place to delirium or coma, so also it is 
only by degrees that the symptoms subside. Never, as in a 
pernicious paroxysm, does the delirium of acute meningitis yield 
in the course of a few minutes ; never is the coma dissipated with 
a rapidity that partakes of the marvellous. The abrupt cessation 
of very dangerous symptoms ; — the calm which succeeds to them ; 
their almost instantaneous reappearance ; — such are the pheno- 
mena proper to periodical fever, and which we may in vain seek 
to find in continued affections." 1 

I have said nothing about the distinctions between the several 
forms or varieties of periodical fever itself. After the full de- 
scription that has been given of these varieties, it is hardly ne- 
cessary to do this. I will merely observe that all these forms 
and varieties may run into each other ; they are mutually con- 
vertible ; and not fundamentally and specifically distinct forms of 



Traite des Fievres Intermittentes, p. 339. 



425 



CHAPTER IX. 

THEORY. 

An adequate and complete theory, even of the very simplest 
form of disease, is beyond the reach of our science ; and the dif- 
ficulties in the way of establishing such a theory increase with 
the increasing complexity and obscurity of the diseases to which 
we wish to apply it. Still, as I have already intimated, I have 
no disposition to abjure entirely all attempts to explain and in- 
terpret the phenomena of disease; I do not wish, because we 
cannot render our theories perfect, to reject them altogether. 
Science here, as everywhere else, is in the appreciable phenomena 
with which we deal, and in their ascertainable relations; but there 
is no objection to our endeavoring to interpret these phenomena, 
and these relations, provided only that we do so with a clear com- 
prehension of the nature and scope of the task we have under- 
taken. Bearing in mind that these interpretations are, in their 
very nature, more or less hypothetical and conjectural ; that they 
are entirely subordinate to the facts with which they are con- 
cerned ; that they may be false as well as true : that they are 
never to be treated like the facts and their relations which they 
attempt to explain, as essential and constituent elements of sci- 
ence ; and that our absolute loyalty to the latter is never to be 
impaired by any claims or pretensions of the former ; — bearing 
these things always in mind, we may not only engage with safety 
in these explanations — provided that we do so with becoming 
modesty and caution — but they may even help us somewhat in 
systematizing and arranging our knowledge. 

It can hardly be regarded as hypothetical to say that there is 
a double element in the pathology of periodical fever. This 
double element consists of a perversion of the function of innerv- 
ation, and of local congestions in certain organs and tissues. 
Maillot, and some others, refer the former of these elements to 
irritation of the cerebro-spinal axis. They think that this view 



426 PERIODICAL FEVER. 

is justified by the phenomena during life, and by the alterations 
found in the brain and spinal marrow, and in their membranes, 
after death. Maillot looks upon this affection of the cerebro- 
spinal axis, not as a pure ordinary inflammation, but as a nerv- 
ous irritation — an active neurosis — with a sudden raptus of blood 
to the organs. However this may be, it is quite certain that one 
of the essential elements in the pathology of periodical fever con- 
sists in some modification of the nervous system ; and it is nearer 
the truth, probably, in the present state of our knowledge, to say 
that this modification is peculiar in its character and obscure in 
its nature, instead of attempting to refer it to any of the ordi- 
nary and common morbid conditions of this system. 

It is possible that this lesion of innervation may constitute 
alone the pathology of periodical fever; the disease, in its purest 
and simplest form, may be without any other pathological condi- 
tion ; the local congestions in the liver, spleen, stomach, and so 
on, may be altogether wanting. This, however, it seems to me, 
is not the most probable and rational conclusion to be derived 
from the phenomena of the disease. There is no doubt of the 
general tendency to these local congestions ; there is no doubt of 
their existence in all grave and severe cases ; they are always 
found on examination after death. Under these circumstances, 
although in mild and simple cases of pure intermittent fever, 
there may be no positive evidence of the existence of these 
congestions, and although I admit the possibility that they 
may not be present, still, as I have already said, taking into 
consideration all the circumstances, it seems to me more philo- 
sophical and more rational to conclude that they constitute an 
invariable and essential element in the pathology of this disease, 
than it is to regard them as accidental complications. 

The relations of the lesion of innervation, and of the local con- 
gestions, to each other, and the relative and absolute importance 
of all these — the parts which they respectively play in the inte- 
gral disease which they constitute — must be more or less matters 
of opinion merely. The nervous disturbance constitutes, proba- 
bly, the first visible and tangible link in the chain of morbid 
actions ; it is, probably, the point of departure in the series of 
morbid processes making up the disease; it seems reasonable to 
suppose that it takes precedence of the local congestions, and 
that the latter are under the control of the former. All this, 



THEORY. 427 

however, let it be admitted, may be otherwise ; or, it may be that 
both elements — the nervous lesion and the local congestions — 
instead of being dependent one upon the other, are alike occa- 
sioned by the action on the system of the malarious poison — 
their common and independent cause. 

In regard to the relative and absolute importance of the several 
morbid elements, I cannot say anything that is not altogether 
conjectural. The danger to life would seem to depend, generally, 
upon the intensity of the visceral congestions and irritations ; but 
our knowledge of the nature of the nervous disturbance, and of 
the part which it plays, is so incomplete and so qualified, that it 
is neither very philosophical nor very safe to indulge to any 
great extent in these and similar speculations. It is safe, per- 
haps, to say that the element of periodicity is probably connected 
directly with the lesion of innervation, and not with the local con- 
gestions. 1 

Some of my readers, especially the younger ones, may be not 
a little disappointed that I do not engage in the attempt so often 
undertaken, to lift the veil which hides from us the efficient causes, 
the mechanism, and the essential nature of this mysterious and 
complex phenomenon of periodicity. For their gratification, and 
I trust for their benefit, I shall make two or three remarks upon 
this subject, which, unlike the subject itself, will at least be suf- 
ficiently intelligible. First, then, all the interpretations and 
explanations which have been given of this phenomenon, are 
entirely and absolutely hypothetical ; they are the coinage of the 
brain — the fruits of the imagination and the fancy. Not only so, 
but, in most cases, they are as obviously and glaringly absurd, 
preposterous, and false, as they are hypothetical. They have 
not even the merit of possibility, to say nothing of probability, 
plausibility, or ingenuity. Nowhere, perhaps, in the boundless 

1 Hippocrates attributed tertians and quotidians to a superabundance of bile in 
the first passages, and quotidians to atrabile. Galen referred quotidians to an 
alteration of the pituita : tertians to that of the bile ; and quartans to putrescence 
of the atrabile. The anatomists said that quartans were the result of an obstruc- 
tion occasioned by the minutest atoms; tertians by those a little larger; and quo- 
tidians by the largest. Eayer refers periodical fever to a cerebro-spinal neurosis; 
Guerin de Mamers does the same. Brachet, of Lyons, says it consists in a modi- 
fication of the ganglionic system. Bouillaud calls it an active neurosis. M. Roche 
refers it to a contamination of the blood by the malarious poison. — Maillot, p. 
316, et seq. 



428 PERIODICAL FEVER. 

region of medical speculation, has the rage for hypothesis been 
wilder and crazier than here. Secondly, the essential nature of 
this phenomenon is probably inscrutable. We may analyze it; 
•we may resolve it into its elements; we may ascertain the 
relations of these elements to each other, «&nd to their modifiers 
— we may do all this, and still be as far as ever from its ultimate 
cause, its essential condition, its intimate and absolute nature. 
Who understands, or can comprehend even, the nature of sleep f 
And what reason is there to believe or^ to hope, that the thick 
darkness which has ever wrapped and which still wraps this in- 
termittent physiological phenomenon, so full of mystery and 
wonder, will ever be dispelled f x 

1 Darwin attributed the phenomenon of intermittence to the nutritive movement 
of composition and decomposition, and the periodical recurrence of waking and 
sleep. Reil taught that it was connected with the analogous phenomena of the 
physical universe. Willis referred it to the periodical development of a fermentable 
matter in the blood; De La Boe to the introduction into the blood of an acid, pan- 
creatic juice ; Borelli to an irritation of the nerves of the brain, and of the fibres 
of the heart, occasioned by an acidity or an acrimony developed in the nervous 
fluid. Werlhof referred it to the periodical movement of the earth, while Mead 
and others attributed it to lunar influence, to the alternate action of day and 
night, the direction of the winds, &c. Giannini said intermittence was occasioned 
by the excessive diminution of sensibility during the sweating stage. Gruerin de 
Mamers attributed it to an extraordinary development of nervous influence, its 
concentration upon a given point, its subsequent exhaustion, its renewal, and so 
on. M. Roche finds a sufficient explanation of this phenomenon in the intermit- 
tent character of its causes, and in certain other collateral influences. — Traite des 
Fievres Inter mittentes, p. 270. Bailly, notwithstanding his general good sense, 
labors through many idle pages to show that morbid intermittence is occasioned 
by the diurnal change in the position of the human body, from the upright to the 
recumbent, and vice versa. Maillot concludes this enumeration with the following 
quotation from Monfalcon: "To know that we know nothing is a great deal ; we 
are then much nearer the truth than when we mistake, for this latter, erroneous hypo- 
thesis." 



429 



CHAPTER X. 

TREATMENT. 

To combat the visceral lesions ; to oppose the return of the paroxysms ; to pre- 
vent the occurrence of relapses ; — such is the triple base upon which rests the 
treatment of periodical fever. — Maillot. 

ARTICLE I. 

BILIOUS REMITTENT FEVER. 

Sec. I. — Preliminary. The treatment of the common form of 
bilious remittent fever is pretty well settled ; and although the 
varieties in the character of the disease, in different seasons and 
localities, render necessary certain modifications in the treat- 
ment, the essential principles of this remain the same. 

Sec. II. — Bloodletting. General bleeding is not commonly 
resorted to in the treatment of this disease. There can be no 
doubt however, that in robust and plethoric habits, and where 
there exists no contraindication, either in the circumstances of 
the individual case, or in the prevailing character and constitution 
of the disease, early and moderate general bleeding is of much 
utility. Early in the disease, under these circumstances, where 
the headache is violent, the skin dry and hot, and the pulse full 
and bounding, the symptoms will be moderated by this remedy ; 
but in the absence of these or analogous special indications, it 
would seem to be safer to abstain from general bleeding. Lind 
cautions against bleeding in hot climates. He says great harm 
has been done by English practitioners, who followed the example 
of Sydenham. Sir Gilbert Blane recommends bleeding in athletic 
habits, with high excitement, violent pains, or delirium : but he 
adds these words: "Although the cases requiring bloodletting 
are more frequent in this sort of fever than in typhus, yet great 
caution and nice discernment are necessary with regard to it, in 



430 PERIODICAL FEVER. — BILIOUS REMITTENT FORM. 

all cases, in a hot climate. Bloodletting, unseasonably and in- 
judiciously employed, either endangers life, or has a very remark- 
able effect in protracting recovery, by the insurmountable weak- 
ness it induces." 1 

Topical bleeding, by cups or leeches, is of very great service, 
and of very general application. There are, probably, but few 
cases in which it may not be beneficially applied. This means 
is especially valuable for the removal or diminution of the epi- 
gastric pain, tenderness, and distress. In ordinary practice, cups 
will usually be made use of; and they should be applied across 
the epigastrium and the hypochondria, and repeated according 
to the urgency of the symptoms and the strength of the patient 
until their object is accomplished. The best time for their appli- 
cation is during the febrile exacerbation, when the skin is warm 
and dry ; and the earlier in the disease the better. " As regards 
the stage of the disorder," Dr. Stewardson says, "I should say 
that it was not worthy of much consideration in determining upon 
the propriety of local depletion in cases of an ordinary remittent, 
where considerable epigastric or hypochondriac tenderness coin- 
cided with more or less acceleration of pulse, and heat of skin. 
For although here, as in the more severe disease of hot climates, 
early depletion, *". e., from the first to the fourth day is highly de- 
sirable, in order to shorten its course and diminish the force of 
the local determinations, yet the same danger does not exist as in 
the latter, in reference to depletion at a much later period ; unless, 
of course, where the symptoms of prostration clearly forbid it. I 
would not hesitate, then, to abstract a few ounces of blood under 
the circumstances mentioned, even at a late period of the disorder, 
since it is certainly a point of paramount importance, in the treat- 
ment of remittent, to prevent, as far as practicable, the production 
of those chronic alterations of the spleen and liver, which, when 
once firmly rooted, so generally prove fatal after lengthened suf- 
fering." 2 

Strong determination of blood to the head, indicated by head- 
ache, heat, throbbing, and in some instances delirium, requires 
the application of scarified cups to the temples and back of the 
neck. 

1 Diseases of Seamen, p. 389. 2 Am. Journ. Med. Sci., April, 1842. 



TREATMENT. 431 

Sec. III. — Purgatives. — The use of purgatives in the treatment 
of bilious remittent fever is almost universal. In the United States, 
they are nearly always given at the commencement of the disease, 
and repeated occasionally, during its subsequent course. Differ- 
ent combinations of cathartic substances are adopted by different 
practitioners; but nearly all of them make use of some mercurial 
preparations — either calomel, or blue pill. One of these substances 
is preferred on account of the peculiar action which they are be- 
lieved to exert upon the liver ; and for their efficacy in restoring 
and correcting arrested or depraved secretions. Whatever may 
be the precise mode of action of the mercury, experience seems to 
have demonstrated its usefulness as a purgative in this form of 
disease. From five to ten grains of calomel may be combined 
with ten or fifteen grains of jalap, or with fifteen or twenty grains 
of rhubarb, to constitute a single purgative dose; this may be re- 
peated, if necessary, or it may be followed by an ounce of castor 
oil. Instead of the calomel, ten or fifteen grains of blue pill may 
be made use of. 

Excessive purgation should be avoided. This evil, owing to 
the disastrous influences of a false and preposterous pathological 
theory, has been pretty extensively prevalent throughout many 
portions of our Southern and Western States. Happily for science 
and humanity, like the bastard philosophy whose legitimate off- 
spring it was, it has nearly run its race, and had its day, and is 
fast disappearing from the practice of our art. It is quite enough, 
as a general rule, that two or three consistent stools should be 
procured during each twenty-four hours, for the active period of 
the disease, and one or two, later. If there is intestinal irritation, 
still greater caution is necessary ; and the milder laxatives should 
always be preferred. 

Sec. IV. — Cinchona. The periodical element in the pathology 
of this disease is to be met and neutralized by the great anti- 
periodic remedy — cinchona and its preparations. There is no 
substitute for these. They are universally relied upon for this 
purpose. In all countries, and at all periods, since the discovery 
of the properties of this incomparable and invaluable substance, 
amidst all the conflicting dogmas of different medical doctrines, 
Peruvian bark has never failed to sustain its reputation, and to 
answer the expectations that have rested upon it. Amidst the 



432 PERIODICAL FEVER.— BILIOUS REMITTENT FORM. 

manifold uncertainties of medical science, and the perpetual 
contingencies of medical art ; amidst the disheartening scientific 
infidelity which has lately been taking possession of the medical 
mind, shaking to its deep foundations the firm old faith in the 
potency of drugs, and threatening to overturn and demolish it 
altogether — it is gratifying and consolatory to feel and to know, 
that here at least we stand upon solid ground, that here we may 
hold — that there is at least one great and important therapeutical 
relationship definitively and positively ascertained and established, 
defying alike the open assaults of quackery from without, and the 
treacherous machinations of indolent skepticism from within. 

The sulphate of quinine is altogether the best of the prepara- 
tions of the bark, and it is now almost universally and exclusively 
used. There is a good deal of difference in the mode and cir- 
cumstances of its administration, by different practitioners — a 
difference that is probably rendered necessary by modifications 
in the character of the disease itself. As a general rule, in the 
treatment of the common form of bilious remittent fever, practi- 
tioners desire to diminish the intensity of the local congestions 
and irritations, by depletion and purgatives ; to lessen the general 
febrile excitement, and thus to develop the periodical element in 
the disease, by rendering the remissions more distinct, before 
resorting to the use of the quinine. Two or three grains an hour 
are then usually given during the period of remission. Some 
physicians prefer very much larger doses — fifteen or twenty 
grains, for instance — given at once, and repeated, if necessary. 
Other observers attach less importance to the preparation of the 
system, by bloodletting, cathartics, &c, for the quinine, and re- 
sort immediately, and without much regard to the stage of the 
disease, to its use. There seems to be good ground for believing, 
as I have just intimated, that these differences may have arisen 
from differences in the character of the disease. It appears pro- 
bable, for instance, that, in the more northern and temperate 
latitudes, it is more necessary to prepare the way for the use of 
quinine, by the preliminary remedies before mentioned, than it 
is in the more southern and warmer latitudes. In these latitudes, 
the disease may sometimes assume a graver character than it 
wears in the former, verging towards its congestive co-gener, and 
requiring somewhat the same treatment that is necessary in the 
latter. 



TREATMENT. 433 

Sec. V. — Diaphoretics ; Refrigerants, $c. Remedies of this 
class are generally made use of, especially during the height of 
the febrile paroxysm. Small doses of ipecac, nitrate of potash, 
and spirit of mindererus, are amongst the articles most frequently 
selected — the choice depending upon the circumstances of the 
case, or the opinions of the practitioner. Cold drinks, acidulated 
or not, effervescing draughts, and so on, according to the taste of 
the patient, should be freely administered. 



ARTICLE II. 

CONGESTIVE FEVER. 

Although the general indications in the management of the 
congestive variety of periodical fever may be nearly the same as 
in that of the bilious remittent form, very important modifications 
are necessary in the details of the treatment and in the applica- 
tion of remedies. In no other disease, of so grave a character, 
does so much depend upon the prompt, efficient, and judicious 
interference of art ; under no other circumstances, of ordinary 
acute disease, is the life of the patient placed so absolutely in the 
hands of his physician. A blow struck at the right time, in the 
right place, and in the right direction, will very often save the 
life that would otherwise have been lost. And the action of the 
physician in the treatment of this terrible form of disease is 
crowded into the briefest space of time ; the issues of life and 
death hang upon a single hour ; the morbid processes must be 
immediately arrested, or modified, or they will inflict irreparable 
and fatal injury upon the organs in which they are situated. 

In laying down rules for the treatment of congestive fever, I 
shall rely mostly upon the observation and experience of the 
physicians of our Southern and Western States. They have long 
been extensively familiar with the disease in all its phases, and 
in its gravest form ; they have studied carefully and attentively 
its therapeutical relationships ; they have been, for the most part, 
sufficiently free from the influence of preconceived opinions and 
doctrinal theories, to look steadily at Nature and to follow its 
teachings, and I regard their authority upon this subject as 
high at least as any in the world. There are, as might naturally 
enough be expected, some differences amongst them ; but, so far 
28 



v^ 



434 PERIODICAL FEVER. — CONGESTIVE FORM. 

as the most important and fundamental principles of treatment 
are concerned, they are very well agreed. 

I shall first speak of the means that are usually resorted to 
during the cold fit — a condition which appertains to all the va- 
rieties of the disease — in what is commonly called the congestive 
chill — in order to bring about reaction. External heat and stimu- 
lants, and internal stimuli, are generally relied upon for this pur- 
pose. Hot bricks, or bottles of hot water, are applied to the 
legs; and the surface of the body is extensively covered with 
sinapisms. Small quantities of brandy, or wine whey, porter, or 
some similar article, are frequently repeated internally. At the 
same time, the sheet-anchor is to be at once thrown out — the great 
remedy is to be immediately and boldly resorted to. The sul- 
phate of quinine, usually in combination with some other articles, 
according to the circumstances and condition of the patient, is to 
be freely given. From ten to twenty grains of the sulphate 
should be administered, either alone or in combination with half 
a grain, or a grain, of one of the salts of morphia, with a few 
grains of calomel, or blue pill, according to the indications. 

Dr. Charles Parry, during the chill, applies hot bricks to the 
feet, and sinapisms over the belly and legs. Every half hour, 
he gives a pill composed of one-fifth of a grain of sulphate of 
morphia, one grain of camphor, two grains of blue pill, and some- 
times .half a grain of capsicum. If there is much blood in the 
discharges from the bowels, and these are frequent, he gives 
every half hour one-fifth of a grain of sulphate of morphia, three 
grains of sugar of lead, and two grains of calomel. He prefers 
ice, internally, to stimuli. If there is much purging, he makes 
use of opium ; and to diminish the local congestions, he applies 
cups and ice. To prevent the return of the paroxysm, his great 
remedy, is of course, quinine. 

Dr. Wharton, of Grand Gulf, Mississippi, applies blisters to 
the thighs, and sinapisms over the belly. He administers at the 
same time, every hour or two, from four to seven grains of 
quinine, combined with capsicum and camphor. Brandy, he says, 
is often useful in promoting reaction. As soon as this is esta- 
blished, free doses of spirits of turpentine and castor oil are 
given, and repeated till they produce copious tarry discharges. 

Dr. Thomas Barbour, of Pulaski, Tennessee, has published in 
the American Journal of the Medical Sciences, an interesting 



TREATMENT. 435 

paper on the congestive fever of what is called the Tennessee 
Valley, in North Alabama. His treatment of the disease differs 
so much, in some respects, from that which is usually adopted, 
that I think it proper to give an outline of it. 

The principal peculiarities, in the method adopted by Dr. Bar- 
bour, consist of his means of procuring reaction, during the cold 
stage of the disease: these means are bleeding and the cold 
affusion. In ordinary cases, and where there is no contraindi- 
cation, from age, intemperate habits, or feeble and broken-down 
constitutions, he bleeds cautiously, from the arm; keeping the 
finger on the pulse, and watching the effect. If the pulse falters, 
the orifice is to be closed, and diffusible stimuli given; but if it 
rises, and becomes fuller and more regular, as it often does, the 
operation is to be continued till the pulse is well developed. 
When general bleeding is not proper, free cupping is substituted. 
A sinapism is applied over the stomach, and small quantities of 
ice, or iced drink are given. If the bowels are torpid, he makes 
use of moderate doses of calomel, rhubarb, and ipecac. ; if the 
discharges are thin, he suppresses them with moderate doses of 
calomel, camphor, and opium. He then resorts to the cold affu- 
sion, for the application of which, he gives the following direc- 
tions. 

" Have a broad plank placed upon two chairs, at a convenient 
distance apart, and place two vessels of hot water on each side, 
corresponding with the feet and hands ; then strip the patient and 
lay him on his back, on the plank, with his extremities in the hot 
water — having at hand twenty or thirty gallons of spring water, 
or, what would be better, water made colder by ice or salt; pour 
the water from a pitcher, in a full and rapid stream, over the 
chest and abdomen. The second mode which I adopt, particu- 
larly in cases where the brain and spinal marrow are the chief 
seats of congestion, is to place the patient upon a blanket on the 
floor, on his side, and then to dash the cold water as forcibly as 
possible over the head, and along the spinal column. Having 
applied the water, the patient should be quickly wiped and placed 
in bed, and covered with two or three blankets, and smartly 
rubbed, either with dry mustard, flour, or salt, or with spirits of 
turpentine. 

" Under the combined influence of these agencies, reaction, if 
at all possible, soon ensues ; the surface rapidly recovers its na- 



436 PERIODICAL FEVER. — CONGESTIVE FORM. 

tural temperature ; the pulse, from being quick and thready, be- 
comes fuller, softer, and more regular ; the countenance becomes 
fuller and more animated ; and from insatiable thirst, and uncon- 
trollable restlessness, the patient often experiences so much relief, 
that it is not uncommon for him to fall into a quiet and refresh- 
ing sleep, from which he awakes greatly improved. 

" The effects of the cold dash are frequently permanent, and 
complete reaction takes place, followed by rapid convalescence. 
In many instances, however, the effects of the first affusion sub- 
side, and the patient relapses into his former condition of coldness, 
restlessness, and insensibility. In such cases, it is proper to repeat 
the affusion, until complete and permanent reaction takes place, 
which may be confidently anticipated in a large majority of even 
the worst cases, provided it is applied sufficiently early." 1 

As auxiliaries to the cold affusion, Dr. Barbour generally ap- 
plies cups along the course of the spine, over the epigastrium, 
the right hypochondrium, or the bowels, according to the indica- 
tions ; and stimulants to the skin. When there are strong marks 
of cerebral congestion, he applies a blister to the back of the head 
or the neck. He gives light diffusible stimuli, especially porter. 

When, by the above means, moderate reaction is procured, he 
gives from three to five grains of blue mass, five grains of rhu- 
barb, and from half a grain to one grain of opium, every six or 
eight hours, until the secretions become of natural color and con- 
sistence ; and from ten to twenty grains of quinine, with from five 

1 Relying upon what are commonly called rational indications, in the application 
of therapeutical means, nothing certainly can well be imagined more absurd and 
irrational, more directly opposed to all a priori considerations, than this use of gene- 
ral bloodletting, and the free affusion of iced water, to remove the collapse of a con- 
gestive chill. But these rational indications, as they are called, are very frequent- 
ly, notwithstanding their high pretensions, most untrustworthy and treacherous 
guides ; they lead us astray as frequently as in the right path ; and whenever they 
oppose, as they so often do, the lessons of simple experience, they are to be utterly 
contemned and disregarded. It cannot be too often repeated, nor too emphatically 
proclaimed, that therapeutics rests on only one true and immovable basis — that of 
pure observation ; her steps can be guided aright by the light alone of experience. 
So here, as everywhere else, the utility and value of the new method are to be 
settled solely by its results. Its apparent unreasonableness or impropriety is not to 
stand in the way of its adoption, if clinical observation establishes its utility. The 
practice is said to have originated with Dr. Thomas Fearn, of Huntsville, Ala- 
bama. Trial has been made of it by a considerable number of physicians ; it 
deserves further and still more careful study ; for its absolute value can hardly 
be regarded as definitely ascertained and determined. 



TREATMENT. 437 

to ten grains of Dover's powder, every three or four hours. He 
prefers the morning for the administration of the quinine, and the 
evening for that of the aperient. If reaction is violent, with signs 
of local congestion, he again applies cups, and administers calo- 
mel, followed by oil, or an infusion of senna with ginger, and 
repeats either the cold or the tepid affusion. It may sometimes 
be proper to bleed from the arm; but, under these circumstances, 
this should be done with extreme caution, as there is danger of 
excessive prostration. Where the cold stage is protracted for 
several days, with imperfect reaction, or none, Dr. Barbour thinks 
but little can be done; but he would rely, under such circum- 
stances, upon the occasional use of the cold bath ; large and nu- 
merous sinapisms, blisters, hot spirits of turpentine, calomel often 
repeated, large doses of quinine, and the free use of brandy or 
porter. Rice water, barley water, arrowroot gruel, or chicken 
water, are the best articles of diet during the course of the disease 
and also for several days after convalescence commences. After 
the strength of the digestive organs has somewhat improved, 
chicken broth, boiled milk, or milk and mush are appropriate 
for a few days, after which the patient can return to his usual 
diet. For drink during convalescence nothing is so good as old 
porter." 1 

Maillot, an extensive and accurate observer, who saw much of 
periodical fever, in all its forms, in the French military hospitals 
in Africa, insists very strongly upon the necessity, in all the per- 
nicious or congestive varieties, of a prompt and bold use of the 
sulphate of quinine. He says that his medical education and 
philosophy had impressed him with the common notion that qui- 
nine could not be safely given in these diseases, so long as there 
were signs of local irritation or inflammation present, and only 
during the apyrexy. His experience amongst the violent con- 
gestive fevers of the hot malarious region of Algiers soon con- 
vinced him of his mistake ; and his use of the great remedy was 
as free and lavish as that of any of our own practitioners in the 
Southern and Western States. During the paroxysm, in the 
comatose and delirious varieties, he recommends general and local 
bloodletting, and cold applications to the head. Cutaneous re- 
vulsives he also regards as important auxiliaries. In the algid 

1 Anier. Journ. Med. Sci., July, 1841. 



438 PERIODICAL FEVER. — CONGESTIVE FORM. 

variety, he endeavors to promote reaction by the free application 
of sinapisms, and by large doses of ether, given both -by the 
mouth and the rectum. He recommends that compresses, saturat- 
ed with water and ammonia, be placed along the spine, over 
which is to be pressed a hot iron ; and that after their removal 
the parts shall be covered with sinapisms. He attaches but small 
value to cathartics. 

It will have been noticed, in the course of the foregoing de- 
tails, that some of the most important rules of practice, followed 
by most of the older physicians, in the management of periodical 
fever, have been altogether disregarded. I allude particularly to 
the use of quinine, in very large doses, and at all periods of the 
disease, and without regard to those conditions of the system that 
have generally been supposed to contraindicate its use. This 
mode of administering quinine is now almost universally adopted, 
in the grave forms of congestive fever, by the physicians of the 
Southland West ; and both its necessity and its safety have been 
abundantly demonstrated. The paroxysms must be arrested, or 
the patient will die; the only agent in our possession, by which 
this can be done, is the bark and its preparations ; and no time 
is to be lost in their use. There is no evidence that, in this form 
of fever, they have any tendency to increase the intensity of the 
local irritations. 1 

Dr. Thomas Fearn, of Huntsville, Alabama, more than fifteen 
years ago, gave the sulphate of quinine in doses of twenty grains, 
repeated three times, at intervals of one hour ; and the credit of 
having originated this mode of practice has been given to him. 
The late Dr. Perrine, in a letter to Dr. Dewees, says that he used 
large doses of the bark, in the treatment of marsh fevers, given 
during the paroxysms, as early as 1819. As soon as quinine 
was introduced, he used that, in average doses of ten grains, every 
two hours, at any period of the disease, without regard to the state 
of the pulse or shin. He did not find it to interfere with the 
simultaneous use of antiphlogistics or stimulants. 2 

Maillot says : " That treatment which in a malarious region 

1 Note to third edition. — The practice of administering quinine early in the vari- 
ous forms of periodical fever has been becoming more and more general at the 
West and South within the last few years. — Dr. Drake, Dis. N. A., vol. i. p. 789- 
793. 

2 Transylvania Journal, vol. vi. p. 301. 



TREATMENT. 439 

attempts to remove local irritations before administering the sul- 
phate of quinine, which waits to convert a grave into a simple 
intermittent before resorting to febrifuges, prepares for itself 
inevitable reverses." 1 

Lind speaks of the Dutch in Batavia, as early as 1763, ad- 
ministering bark, without waiting for any remission ; and, in 
grave cases, Cleghorn did the same in Minorca, more than a 
hundred years ago. 

About the modus operandi of the sulphate of quinine, I have 
but a single word to say. Certainly, there is no propriety in re- 
garding it as a simple tonic, or stimulant. In congestive fever, 
at least, it does not act as a tonic or stimulant ; and no known 
tonic or stimulant can be substituted for it, or supply its place. 
It is a specific anti-periodic. It is endowed with the peculiar 
property of arresting or counteracting this pathological process 
characterized by periodicity; it stands in a special relation to this 
particular form of disease ; and this is the entire sum and sub- 
stance of our knowledge of the matter — just as easily packed in 
a nutshell as blown out into an empty balloon. 

ARTICLE III. 

INTERMITTENT FEVER. 

It is hardly necessary to enter at any considerable length into 
the details of the treatment appropriate to the simple intermit- 
tent form of periodical fever. The management of simple cl tills 
and fever has been, to a very great extent, taken out of the 
hands of medical men, and entrusted to those of the patients 
themselves and their friends. This management consists almost 
exclusively in the use of the sulphate of quinine ; with occasion- 
ally, perhaps, a simple or a mercurial purgative. The quinine is 
usually given during the intermission, and in various doses — from 
one or two to eight or ten grains. 

Amongst persons constantly residing in malarious localities, 
intermittents frequently become obstinate, irregular, and pro- 
tracted. In these cases, and in the simple forms, when the latter 
resist the influence of quinine, various substitutes for this sub- 

1 Traite des Fievres, etc., p. 81. 



440 PERIODICAL FEVER. — INTERMITTENT FORM. 

stance have been made use of. Amongst these, the most import- 
ant are arsenic, and some of the bitter vegetables — Cornus Florida, 
or dogwood, chamomile, thoroughwort, and so on. There is no 
doubt at all of the anti-periodic property of arsenic ; and in those 
cases to which I have referred, it may sometimes be used with 
advantage. So, an infusion of one of the vegetables just men- 
tioned will occasionally be found more efficacious in arresting the 
paroxysms than even the bark itself; and when the disease does 
not yield to its usual remedy, it is well to employ them. 

In regions where marsh fevers are extensively prevalent, there 
are many remedies and modes of practice besides those already 
mentioned, which acquire a popular celebrity. Most of them pro- 
duce a pretty sudden and powerful impression, either upon the 
mind or the body, and in this way they frequently break up the 
disease. I shall mention particularly only one other remedy, and 
that is opium. This substance has been a good deal used in the 
treatment of periodical fever, and there seems to be no doubt of 
its great value. The following interesting account of its action 
and effects is by James Lind, who, for a long period during the 
last century, was a careful and extensive observer of periodical 
fever. His testimony in regard to its advantages is so emphatic 
and decided that I feel bound to introduce it. The history of his 
experience is thus related. Having given a dose of opium in an 
obstinate case of ague, on account of some accidental symptom, 
to the great relief of the patient, he concluded to try the remedy 
more extensively. "Having, at that time," he says, "twenty- 
five patients laboring under intermitting fevers, I prescribed an 
opiate for each of them, to be taken immediately after the hot 
fit, provided the patient had any inquietude, headache, or similar 
symptom, subsequent to the fever. The consequence was, that 
nineteen in twenty-two received immediate relief; the other three 
had no occasion to take it. 

" Encouraged by this success, I next day ordered the opiate to 
be given during the hot fit. In eleven patients out of twelve to 
whom it was thus administered it removed the headache, abated 
the fever, and produced a profuse sweat, which was soon followed 
by a perfect intermission. Since that time, I have prescribed an 
opiate to upwards of three hundred patients laboring under that 
disease. I observed that, when given during the intermission, it 
had not any effect, either in preventing or mitigating the succeed- 



TKEATMENT. 441 

ing fit; when given in the cold fit, it once or twice seemed to re- 
move it; when given half an hour after the commencement of the 
hot fit, it generally gave immediate relief. 

" The effects of opium, given in the hot fit of an intermitting 
fever, are these : First, it shortens and abates the fit ; and this 
with more certainty than an ounce of bark is found to remove the 
disease. Second, it generally gives a sensible relief to the head ; 
takes off the burning heat of the fever, and occasions a profuse 
sweat. This sweat is attended with an agreeable softness of the 
skin, instead of the disagreeable burning sensation which usually 
affects patients sweating in the hot fit, and is more copious than 
in those who are not under the influence of opium. Third, it 
often produces a soft and refreshing sleep to patients before ha- 
rassed with fever, from which they awake bathed in sweat, and 
in a great measure free from complaint. 

" I have always observed that the effects of opium are more 
uniform and constant in intermitting fevers than in most other 
diseases, and are then more quick and sensible than those of most 
other medicines. An opiate thus given, soon after the commence- 
ment of the hot fit, by abating the violence and lessening the du- 
ration of the fever, preserves the constitution in a great measure 
uninjured. Since I have used opium in agues, a dropsy or jaun- 
dice has seldom attacked any of my patients in these diseases. 

" In cases where opium did not immediately abate the symp- 
toms of the fever, it never augmented their violence. On the 
contrary, most patients reaped some benefit from an opiate given 
in the hot fit; and many of them bore a larger dose of opium 
at that time than at any other. Even a delirium in the hot fit 
is not increased by opium, though opium will not remove it. If 
the patient be delirious in the fit, the administration of the opiate 
ought to be delayed till he recovers his senses; an opiate will 
then be found to relieve the weakness and faintness which com- 
monly succeed the delirium." 1 

Dr. Drake says of opium in the treatment of malignant in- 
termittents : " Of its great value no physician of experience, in 
those diseases, can entertain a doubt. If there be no diarrhoea, 
however, it is not necessary to administer it throughout the inter- 
mission, but reserve it for the last dose of the sulphate, before 

1 Lind on Hot Climates, Phila. ed., p. 236. 



442 PERIODICAL FEVER* — INTERMITTENT FORM. 

the approaching chill. The quantity in which it is then given, 
is often entirely too small, and much better fitted to simple in- 
termjttents, in which the susceptibilities of the system are lively, 
than to those in which they are greatly reduced. In such a state 
of the system, three or four times as much as would be required 
in an ordinary ague, is not a large dose. I have met with many 
physicians who had a just appreciation of this state of the system ; 
but with none who carried the practice logically deducible from 
it, so far as Dr. Merriman and Dr. Henry, of Springfield, Illi- 
nois. It has grown into a settled opinion with those gentlemen, 
that a moderate quantity of the sulphate, combined with a large 
quantity of opium, is the very best practice. Hence through 
the early periods of the intermission, they do little or nothing; 
but three or four hours before the chill, administer a bolus of 
four grains of opium and eight grains of sulphate, which, as 
they affirm, scarcely ever fails. Dr. Henry has even found that 
dose of opium, without the other medicine, successful. Dr. Jayne 
pursues the same practice, but generally limits the opium to two 
grains." 1 

To prevent the occurrence of relapses, I know of no means of 
any value, except an occasional use of the bark ; a careful regu- 
lation of the diet and exercise, so as to keep the system in as 
vigorous a tone as possible ; and an avoidance of the night air, 
and of all the ordinary exciting causes of disease. There is only 
one means certainly to be depended upon, and this consists in a 
removal beyond the influence of the malarious poison. 

For the removal of the various remote consequences of the dis- 
ease which have already been enumerated, no very particular 
rules can be given. The local engorgements of the liver and 
spleen — especially of the latter — so long as they are simple en- 
gorgements, without any fixed change of structure, are to be met 
by the means already indicated, particularly by quinine, paying 
attention at the same time to the state of the bowels and secre- 
tions. When these engorgements have been so long continued 
and so often repeated, as to result in chronic structural altera- 
tions, only palliative effects can be looked for from remedies. 
The headache and other cerebral troubles, which sometimes follow 
the disease, and which seem to be connected with a kind of nerv- 

1 Dr. Drake on the Diseases of North America, vol. i. p. 776. 



TREATMENT. 443 

ous erethism, may generally be removed by shaving the head 
and keeping it cool; by quiet and rest; and a careful regulation 
of all the organic and animal functions. Neuralgic affections are 
to be treated upon the same general principles. There can be but 
little doubt, that a free and persevering use of cold water, ex- 
ternally and internally, with a plain but substantial diet, and 
active exercise in the open air, would constitute the best possible 
treatment in many of these cases. The best special remedy for 
the anemic condition which the disease frequently leaves behind 
it consists in the different preparations of iron. 



444 



CHAPTER XI. 

DEFINITION. 

There is so wide and various a range in the forms of periodical 
fever, that it is very difficult to frame any definition of it, which 
shall possess the necessary brevity, and at the same time be 
sufficiently comprehensive to include all the essential features of 
the disease. I can come no nearer the fulfilment of these condi- 
tions than in the following endeavor. 

Periodical fever is an acute affection ; occurring at all periods 
of life; much more common in the white than in the negro race; 
confined to certain geographical localities, and prevailing most 
extensively, as an annual endemic, in marshy and uncultivated 
regions, and along low-lying and luxuriant alluvions; mostly 
confined in temperate climates to the latter part of the hot season 
of the year ; immediately excited, in many instances, by the ordi- 
nary occasional causes of acute disease, such as exposure and 
excesses ; dependent for its essential cause upon a poison called 
marsh miasm or malaria, the nature and composition of which are 
unknown ; — generally, sudden in its access ; commencing with a 
rigor or chill, which is succeeded first by febrile excitement, and 
then by general perspiration — these successive phenomena con- 
stituting the three stages of what is called the paroxysm of the 
disease ; this paroxysm having a tendency to recur, or to repeat 
itself, more or less regularly, at certain definite periods, and after 
certain intervals — these intervals constituting the remissions or 
intermissions of the fever ; the paroxysms and intervals being in 
an immense majority of instances, either diurnal or bi-diurnal in 
their recurrence ; the symptomatic phenomena constituting these 
periodical stages varying very widely in their intensity and com- 
binations, thus giving rise to numerous fluctuating and diverse 
forms of disease ; the simpler varieties attended with but little 
immediate danger, and continuing from a few days to an inde- 
finite period of time ; the graver and pernicious forms dangerous 



DEFINITION. 445 

in their tendency, and speedily fatal in their results, unless 
promptly arrested by art ; all the varieties, if long continued, or 
often repeated, finally undermining the constitution, and occasion- 
ing various structural alterations, especially of the spleen, attended 
by dropsical effusions, anemia, general debility, and neuralgic 
pains; the bodies of patients exhibiting, on examination after 
death, in most cases, hypersemic irritation of the cerebro-spinal 
axis; in nearly all, redness, softening, thickening, thinning, and 
mamellonation — one or more — of the mucous membrane of the 
stomach ; and in all cases, a bronze or olive color of the liver, 
enlargement and softening of the spleen, and a diminution in the 
normal quantity of the fibrine of the blood ; — which disease, thus 
characterized and defined, sustains a special therapeutic relation 
to cinchona and its preparations, and is to a great extent modified 
and controlled by them. 



446 



CHAPTER XII. 

BIBLIOGRAPHY. m 

Observations on the Epidemical Diseases of Minorca, etc. By 
G-eorge Cleghorn, M. D. Philadelphia, 1812. This admirable 
little book was written more than a century ago. It is a model 
of the class to which it belongs, and a fit companion to Hillary's 
similar book on the diseases of Barbadoes. Dr. Cleghorn's 
description of the several forms and varieties of malarious fever is 
very full and complete ; and the disease seems to have been as judi- 
ciously and efficiently treated, a hundred years ago, as it is now 
■ — excepting in the advantages derived from the possession of 
quinine. Dr. Cleghorn used the bark early and freely ; and he 
regrets that he had not always given it with as much freedom as 
he did during the last seven years of his practice in Minorca. 
In grave or threatening cases, he urges the importance of the 
hark, without regard to the state of the system — the presence of 
offendiny matters in the bowels, the existence of local inflammation, 
and so on. 

A Treatise on the Hidden Nature, and the Treatment of 
Intermitting and Remitting Fevers, etc. By Jean Senac. 
Translated from the Latin, by Charles Caldwell, M. D. Phila- 
delphia, 1805. Senac's book is one of the classics in this de- 
partment of medicine. He practised in Paris, during the reign 
of Louis XV., when periodical fevers were more common than at 
present. His treatise is systematic and elaborate ; his description 
of the mixed, irregular, and masked forms of the disease is 
particularly full and valuable. He speaks of the bark as a 
divine discovery. The Treatise has a good deal of useless 
rationalism ; but its practical portion is excellent, and it is, on 
the whole, a capital old book. 

Observations on the Causes and Cure of Remitting, or Bilious 
Fevers. By William Currie, M. D. Philadelphia, 1798. I 
have already, on other occasions, had the pleasure of commending 



BIBLIOGRAPHY. 447 

this excellent little book. Its style is clear, simple, and unpretend- 
ing ; its descriptions are full and accurate; and it is quite free 
from the false philosophy which pervades, obscures, and vitiates, 
all the writings of Dr. Currie's great contemporary and fellow- 
citizen, Dr. Rush. The radical differences between bilious re- 
mittent and yellow fever, are very fully and clearly stated. 

An Essay on the Diseases of Hot Climates, etc. By James 
Bind, M. D. Philadelphia, 1811. This somewhat celebrated 
work contains short and cursory notices of many of the localities 
in hot climates, which are in the hands of the more northern 
nations, or which are often visited by Europeans; and of the 
principal diseases — especially fevers — to which they are subject. 
The book is marked by good sense ; though its contents are not 
now of any special value. 

The Influence of Tropical Climates on European Constitutions, 
etc. By James Johnson, M. D. This is the celebrated work of 
the celebrated editor of the Medico- Chirurgical Review, on the 
diseases of hot climates. There are few medical books which 
have been so extensively read in this country ; there are few that 
have been so generally popular; and there are none that have 
been so over-estimated and over-praised. No English work has, 
directly and indirectly, exerted so powerful an influence upon 
medicine in the Western States as this. 1 This influence may be 
distinctly seen, not only in the popular pathology and practice of 
these States, but in the prevailing style of writing, and modes of 
expression, amongst medical men. The style of Dr. Johnson's 
book is free, fluent, rambling and slashing, with a copious sprin- 
kling of scraps of poetry, native and foreign. His pathology 
abounds in excitability, venous congestion, stagnation of the blood 
in the portal circle, balance of the circulation, and similar hypo- 
thetical fancies. His descriptions of disease are entirely without 
value. One of the most sensible remarks in the book is this : 
" The opinion that these grand endemics, yellow fever, for in- 
stance, are only the bilious remittents of all tropical climates, in a 
more concentrated state or degree, is founded, I fear, on too great 
a rage for generalizing." 

1 The monstrous pathology of Dr. Cooke, and the still more monstrous practice 
growing out of it, are only elaborate exaggerations and caricatures of thepathology 
and therapeutics of this "work. 



448 PERIODICAL FEVER. 

Traite des Fievres Pernicieuses Inter mittentes. Par J. L. 
Alibert. 5th edit. Paris, 1820. This work of Alibert is mostly 
a compilation ; and I have been able to find but very little in it 
of any value. 

Traite Anatomico-Pathologique des Fievres Intermittentes, Sim- 
ple et Pernicieuses ; etc. Par F. M. Bailly, de Blois. Paris, 
1825, pp. 535. 

This is a large and substantial treatise upon periodical fever. 
Its author is a Frenchman, who studied his subject mostly at 
Rome, in the year 1822, amongst the patients of the great hos- 
pital of the Holy Spirit. Altogether the least valuable portion 
of the book is the first long chapter of one hundred and twenty 
pages. This is made up of a very elaborate and very tedious 
statement and development of the author's notions about the 
nature of periodical fever, the cause of periodicity, &c, with 
theories of waking and sleep, inflammation, and crises. I will 
merely say of it, further, that he attributes the phenomenon of 
intermittence to the diurnal change which takes place in the 
position of the human body. It would be an idle and a useless 
task to repeat the reasoning which leads him to this conclusion. 
It is a great pity, that so sensible a writer should attach so much 
importance to speculations so entirely empty and visionary. The 
great fault of the book consists in its diffuse verbosity, and its 
constant efforts to explain and interpret the phenomena of dis- 
ease. There is nothing of any special importance in its thera- 
peutics. The author insists earnestly upon the twofold element 
constituting periodical fever — the nervous disturbance, and the 
local congestions and inflammations — and his principal means 
for meeting the double indication, growing out of this pathologi- 
cal doctrine, consist of bloodletting, purgatives, and cinchona. 
The latter he regards, not as a stimulant or tonic, but as a pecu- 
liar anti-periodic, and nervous sedative. Ligatures upon the 
limbs, he says, will frequently prevent the occurrence of an ex- 
pected paroxysm. 

An Fssay on the Remittent and Intermittent Diseases, including 
generically Marsh Fever and Neuralgia. By John Macculloch, 
M. B., F. B. S., etc. etc. Dr. Macculloch vaults at once into 
the saddle of his hobby, by announcing, in the first sentence of 
his preface, his conviction of the intimate dependence of neuralgia 
upon intermittent fever. The leading idea of the whole work is 



BIBLIOGRAPHY. 449 

to be found in the almost boundless extent and variety of action 
which he attributes to malaria, in the production of disease; its 
leading, philosophical error consists in this broad, loose, and 
sweeping generalization. Dr. Macculloch's style is involved and 
clumsy; but he writes from clear and strong conviction, and no 
one can wade through the episodical but racy prolixity of his 
heavy pages, without a strong feeling of his logical acuteness, his 
good sense, and his freedom from professional cant. His hardest 
and favorite hits — well merited and well put in — are at Sangra- 
doism, asceticism, and the then fashionable practice of daily 
purging with "calomel and salts." There are other and more 
extensive localities than the British islands which might profit by 
his warnings. 

Sketches of the most prevalent Diseases of India. By James 
Annesley, Esquire. London, 1829. Mr. Annesley had ample 
opportunities for the study of periodical fever, in its several 
forms, during his residence in the British East Indies ; but he 
has contributed very little in this work to our knowledge on this 
subject. There is no description of the fever, and the book is 
overloaded with gratuitous and hypothetical fancies, which the 
writer very sincerely and honestly mistakes for principles ! 

Traite des Fievres, ou Irritations cerebro-spinales Intermit- 
tentes, d'apres des observations recueilles en France, en Corse, et 
en Afrique. Par F. O. Maillot. Paris, 1836, pp. 420. 

In an earnest and straightforward introduction of only five 
pages, M. Maillot awakens the interest and wins the confidence 
of his readers. He indicates the general character of his work, 
and makes amongst others these two remarks. In the midst of 
the numerous works, he says, which have followed each other 
upon this obscure subject of intermittent fever, there is one idea 
which is tending to become more and more predominant, namely, 
that which refers these fevers to a lesion of the nervous system. 
This, he adds, was the opinion of Boerhaave, of Cullen, of Borelli, 
of J. P. Frank, of Fodere, of Giannini, of Georget, etc. ; and in 
the present day of Alibert, Rayer, Bricheteau, Brachet, Nepple, 
and others. The cerebro-spinal axis he looks upon as the point 
of departure of the series of morbid actions constituting periodical 
fever; but pathological anatomy has demonstrated, he says, that 
there is something superadded to the neurosis, and that this is an 
acute irritation or hyperemia of the great nervous centres. The 
29 



450 PERIODICAL FEVER. 

treatment, he says, which consisted in removing or attempting to 
remove the local irritations and congestions, before the adminis- 
tration of cinchona was allowed, failed in hot climates and mala- 
rious regions; and it became necessary to fall bach upon the 
method of Fore, that of giving large doses of this remedy during 
the paroxysm, and while the tongue indicated active gastric excite- 
ment. I have made free use of Maillot's excellent and accurate 
observations in various parts of my book. He has contributed 
largely to our knowledge of periodical fever, especially as it shows 
itself in hot climates. Every part of his work abounds in positive 
and reliable information ; and it is generally pervaded by a cau- 
tious and sound philosophy. It is interesting to witness the 
exact coincidence between his convictions — the result of extensive 
experience, forced upon him in opposition to his previous opinions 
— and those of many observers in our own country, of the safety 
and necessity of large doses of quinine, in the graver forms of 
periodical fever, regardless alike of any signs of local irritation 
or inflammation, and of the particular period of the disease. In 
one of his reported cases of comatose intermittent, occurring at 
Bona, in 1835, he gave, in the course of a few hours, eighty grains 
of sulphate of quinine, by the stomach, and sixty in an injection, 
all during the paroxysm. On the second day, the patient took 
forty grains, and twenty-four on the third ; the following day, he 
was convalescent. 

Medical History of the Expedition to the Niger, during the 
years 1841 and 1842, etc. By James Ormiston M ' William, 
M. D. In the year 1841, an expedition was fitted out by the 
British government, to the Biver Niger in Africa — the leading 
object of which was to promote the abolition of the slave-trade. 
The expedition consisted of three iron steam-vessels, the Albert, 
the Wilberforce, and the Soudan; and of one transport for stores. 
The expedition left England in May, 1841, and entered the Niger 
on the 13th of August. When the four vessels entered the new 
branch of the Niger, the following was their complement of officers 
and men — many of the Kroomen and liberated African boys 
having joined the vessels on the coast: Officers, 53; white 
seamen, 63 ; marines and sappers, 29 ; men of color entered in 
England, 25 ; Kroomen and liberated Africans, entered on the 
coast, 110 ; blacks for model farm, 23 ; grand total, 303. The 
expedition went on very successfully, the officers and men all in 



BIBLIOGRAPHY. 451 

good health and high spirits, until it had passed the delta of the 
river, and arrived at the town of Iddah, in the kingdom of Eggana. 
nearly two hundred and fifty miles from the mouth. This was 
on the 2d of September, and on the 4th, fever of a most malig- 
nant character appeared in all the vessels. It spread with great 
rapidity ; and on the 9th, the first death took place, that of the 
captain's steward, of the Soudan. On the 11th, there were two 
deaths ; on the 17th, there were sixty-nine sick, and there had 
been seven deaths. On the 19th, the Soudan, with forty eases 
of fever on board, started for the mouth of the river ; and on the 
21st, the Wilberforce followed ; leaving the Albert to go on her 
dreary way alone — convoyed by tornadoes, tempests, savagery, 
pestilence, and death. By the 3d of October, the Albert having 
reached Egga, some three hundred and fifty miles from the sea, 
there were only seven persons on board well enough to do duty. 
and the Albert also abandoned the enterprise, and turned her 
prow towards the Atlantic. On the 8th, in the night, one of the 
patients, in delirium, jumped overboard, but was saved ; the next 
morning, the second engineer threw himself into the river, and 
was drowned. On the 17th, the three steamers arrived at the 
island of Fernando Po. "On the 16th of December," says Dr. 
M' William, "Dr. Vogel, the botanist of the expedition, died, and 
in the evening his body was deposited in the burial-ground at 
Fernando Po, by torchlight. It was pitch dark, and the stars. 
seen through the dense foliage, were the only objects in nature 
that relieved the surrounding dismal gloom. At every step, we 
trod over our former messmates or fellow-laborers. As near as 
•possible to the grave of Lander, lie thirteen of the Niger expedi- 
tion, who, like himself, fell in the cause of Africa." The whole 
number of deaths from fever, during the expedition, was forty- 
two ; all of which were amongst the whites. The whole number 
of whites, in the three steam-vessels, up and down the Niger, 
was one hundred and forty-five ; all these were attacked except 
fifteen. The whole number of blacks was one hundred and fifty- 
eight ; of whom only eleven had the fever, and these in a mild 
form. 

Dr. M' William's description of the disease is very incomplete 
and unsatisfactory. It was evidently remittent, many of the 
cases being congestive or malignant. There was no case of black 
vomit ; and, indeed, there seems to have been little or no resem- 



i 



452 PERIODICAL FEVER. 

blance between it and yellow fever ; although* Dr. M'William not 
only makes no distinction between the two diseases, but evidently 
confounds them. 

Dr. M'William was sent in 1846, by the Admiralty Commis- 
sioners, to investigate the circumstances attending the prevalence 
of a malignant disease, at Boa Vista, one of the Cape de Verd 
Islands, in 1845. The disease, which was yellow fever, showed 
itself first on board the British ship Eclair, during the passage 
from the coast of Africa. It occurred at Boa Vista, for the first 
time, nearly a month after the departure of the Eclair. 

A Practical Medico- Historical Account of the Western Coast 
of Africa, etc. By James Boyle, London, 1881. Mr. Boyle 
occupied different positions as a medical officer, in the British 
stations on the western coast of Africa, between the years 1822 
and 1831. His volume, of more than four hundred pages, consti- 
tutes, he says, the first systematic treatise on the diseases of 
western Africa. It is very desultory and immethodical in its 
plan, and is written in an awkward and ungraceful manner. The 
first seventy pages are occupied with the medical topography of 
the western coast, from the River Gambia southward to Sierra 
Leone. Sluggish, muddy rivers, swarming with alligators, hip- 
popotami, and mosquitoes, their low banks covered with a rank 
growth of bush and mangrove ; deluging rains and devastating 
tornadoes, one-half the year, and the fiery and blinding harmatan 
the other ; and an average temperature, during each of the twelve 
months, of at least 80° of Fahrenheit, make up the prominent 
features of the scene ! Mr. Boyle describes two forms of endemic 
fever — the climatorial bilious remittent, and the local endemic 
bilious remittent, as he calls them. There is no evidence that 
there is any essential difference between them. His descriptions 
of the African fever are very short, sketchy, and imperfect. The 
strongest impression left upon the mind by the reading of this 
book, is that of the terribly pestiferous and malignant character 
of this region, so far as the northern races are concerned. Surgeon 
Tedlie says that, although the Gold Coast has a moderate range 
of temperature, the mercury rarely rising higher than 85°, or 
falling lower than 76°, it is more unfriendly to the European 
constitution than any other country on the face of the globe. 
No European, he says, ever escapes the fever. The first attack 
is the regular remittent, called the seasoning, after which the 



BIBLIOGRAPHY. 453 

person is still subject to remittents and intermittens, more or 
less irregular in their character. Yellow fever rarely occurs on 
the coast. It visited Sierra Leone in 1823 and 1829, attacking 
old residents as violently as more recent comers. 

The articles on intermittent and remittent fever, in the Library 
of Practical Medicine, are by Dr. Shapter. They are compila- 
tions ; and, so far from containing anything new, they are very 
far from embodying our actual knowledge upon the subjects of 
which they treat. 

The articles in the Cyclopaedia of Practical Medicine are by 
Dr. Joseph Brown. The same remarks may be made of them, as 
of the foregoing. 

The American Medical Journals contain many original articles 
upon the several forms of periodical fever, of much value. 

A Systematic Treatise, Historical, Etiological, and Practical, 
on the Principal Diseases of the Interior Valley of North America 
as they appear in the Caucasian, African, Indian, and Esqui- 
maux varieties of its Population. By Daniel Drake, M. D. 
Cincinnati, 1850 : pp. 878. 

This is the first volume of the great work of the learned and 
veteran physician of the West, Dr. Drake, on the Diseases of the 
Interior Valley of North America. It has been long promised by 
its distinguished author, and impatiently waited for by his many 
friends and pupils, throughout that wide and wonderful region, 
where his name has been a familiar household word for so long 
a period of time. These friends and pupils, and the profession 
generally, will not be disappointed, I think, in this result of Dr. 
Drake's labors. This first volume contains the fruits of a vast 
amount of personal observation and research, as carefully and 
thoroughly made as circumstances allowed. It is an immense 
magazine and storehouse of important and valuable facts, from 
which all future historians and observers, working in the same* 
great field, will derive many of their best aids and their richest 
materials. 



PART FOURTH. 



THE 



HISTORY, DIAGNOSIS, AND TREATMENT 



OF 



YELLOW FEVEK 



PART IV. 
YELLOW FEVER. 



CHAPTER I. 

NAMES OF THE DISEASE. 

Yellow Fever has received a goodly number and variety of 
appellations ; this, its most common name with English, French, 
and American writers, was very naturally derived from that 
striking and common phenomenon in its natural history, the yel- 
low discoloration of the skin. One of its earliest names was that 
of mat de Siam — disease of Siam — first given to it by the Domi- 
nican, Father Labat, near the close of the seventeenth century, 
from the belief that it was derived from that country. Chis- 
holm calls it a Malignant Pestilential Fever; Lempriere calls 
it Tropical Continued Fever ; Burnett calls it Mediterranean 
Fever ; many call it the Bulam or Boullam Fever; and various 
other names have been given to it. Amongst the many names 
which systematic writers have applied to it are the following, to 
wit : Typhus icterodes ; Flodes icterodes ; Febris maligna biliosa 
Americse; Causus tropicus endemicus, etc. etc. 



458 



CHAPTER II 

SYMPTOMS. 



ARTICLE I. 



MODE AND PERIOD OF ACCESS. 



Yellow fever is almost always marked by a distinct and formal 
access, so that the precise period of its commencement can be 
generally fixed with great precision and certainty. The most 
constant initiatory symptoms are chills ; and pains,, often violent, 
in the head, back, and limbs — the latter not unfrequently being 
very severely felt in the calves of the legs. Dr. Barrington, in 
his account of the disease, as it prevailed on board the vessels of 
the United States Navy, and at Pensacola, in 1828, 1829, and 
1830, says that, in a few cases, the fever was ushered in by an 
acute pain felt in some spot, and afterwards becoming general. 
"In one patient, on board the Grampus, the penis was the seat of 
this suffering ; in another, the attack was announced by a neu- 
ralgic affection of the right temple. In several, the knees were 
alone complained of at first ; and in four patients, in the Hornet, 
a spasmodic affection of the muscles of the leg was the prelude." 1 
In what proportion of cases this well-marked commencement of 
the disease is preceded by premonitory symptoms, I am unable to 
say with any degree of accuracy, the statements of most ob- 
servers upon this point being made only in general terms. It 
is quite certain, however, that, in many instances, the person re- 
ceives no warning of the approach of the disease ; he is stricken 
down in an instant, no shadow of the coming blow having fallen 
upon him. Dr. Rush, in his description of the yellow fever of 
1793, in Philadelphia, says : "Many went to bed in good health, 
and awoke in the night with a chilly fit. Many rose in the morn- 
ing, after regular and natural sleep, and were seized at their work, 

1 Amer. Journ. Med. Sci., Aug. 1833. 



SYMPTOMS.— MODE AND PERIOD OF ACCESS. 459 

or after a walk, with a sudden and unexpected attack of the 
fever." 1 Dr. Barrington says that, in a majority of instances, the 
onset was without any previous indisposition. 

In other cases, this distinct commencement of the disease is 
preceded for some hours, or for some days, by certain premoni- 
tory symptoms. There is nothing constant or invariable in the 
character of these ; sometimes they consist of moderate febrile ex- 
citement, and at others of various disturbances of the nervous and 
digestive functions. Dr. Rush enumerates nearly twenty of these 
precursory signs ; but they are, none of them, sufficiently uniform 
in their occurrence, or sufficiently characteristic of the disease, to 
render it worth while to repeat them. 

It is alleged by many observers, that the attack of yellow fever 
occurs much more frequently during the night than during the 
day. Dr. Rush says : "A great proportion of all who were 
affected by this fever were attacked in the night." 2 Dr. Barring- 
ton says, that the time of the onset was generally between sunset 
and sunrise. 3 Dr. T. A. Cooke, in a paper in the New Orleans 
Medical and Surgical Journal, on the Epidemic Yellow Fever 
which prevailed at Opelousas, in the years 1837, 1839, and 1842, 
says that, in the two former years, the attack came on suddenly, 
rarely with premonitory symptoms, and, in a large majority of 
cases, between the hours of midnight and daybreak. I do not 
know that this greater liability to an attack of the disease during 
the night is formally contradicted by any writers ; but there are 
many who say nothing about it ; and it can hardly be regarded 
as an unreasonable skepticism to say that the question must be 
determined by further, more extensive, and more accurate ob- 
servation. In his description of the epidemic of 1828, at Gibral- 
tar, Louis merely remarks that the disease commenced at different 
hours of the day, sometimes in the night ; and I find, on looking 
over the only cases, seven in number, reported by him, in which 
the time of attack is particularly mentioned, that this was during 
the day in two ; at five P. M., seven P. M., and eight P. M., in 
one each ; in the morning, in one ; and in the night, in one. Of 
five cases, occurring in the Charity Hospital, at New Orleans, in 
1843, and reported by Dr. Slade, the attack took place during 

1 Rush's Med. Inq., vol. iii. p. 52. 2 Ibid., vol. iii. p. 51. 

3 Amer. Journ. Med. Sci., Aug. 1833. 



460 YELLOW FEVER. 

the day in one ; and at five A. M., eight A. M., and eleven A. M.' 
in one each. 1 Dr. E. B. Harris has reported twenty cases, which 
occurred at New Orleans, in 1833. The time of attack is particu- 
larly stated in sixteen, and in only two of these was the attack in 
the night. 2 

ARTICLE II. 

FEBRILE SYMPTOMS. 

Sec. I. — Chills. There is probably no disease, unless it is 
puerperal peritonitis, the access of which is more invariably at- 
tended by a chill or rigor than this. The testimony of observers 
is so uniform upon this point, that it is quite needless to accumu- 
late authorities. It is present alike in mild, grave, and fatal 
cases, with one exception, perhaps, which will be mentioned 
hereafter, in speaking of a very singular and striking form or 
variety of the disease. The chill is almost always one of the 
first symptoms ; although, in a very few cases, it takes place some 
hours, or even a day or two, after the formal commencement of 
the fever. The chill is sometimes severe, but generally moderate, 
of short duration, and is rarely though it is occasionally repeated. 

Sec. II. — Temperature of the Surface; Sweats. Following 
the initial chill, there is frequently increased heat of the surface ; 
but this heat is only moderate. The high and burning heat of 
continued fever, and of some of the eruptive fevers, is never 
present ; and in very many cases the skin never rises above its 
natural temperature. The increased heat, in those cases where 
it is present, rarely continues beyond the second or third day; 
rapidly giving place, in cases that are running on towards a fatal 
termination, to coldness of the surface, beginning usually in the 
extremities, and more striking here than in other parts of the 
body. According to Louis and Trousseau, coldness of the lower 
extremities is a very constant attendant upon the black vomit, a 
symptom that will be particularly described hereafter. 

In a certain number of cases, there is more or less perspiration ; 
in others, the skin preserves its natural softness and moisture ; 

1 N. 0. Med. and Surg. Journ., vol. i. p. 85. 2 Amer. Journ. Med. Sci., May, 1834. 



SYMPTOMS. — PULSE. 461 

it is not often morbidly dry. Dr. Lewis, of Mobile, says there 
is a natural tendency to perspiration. Dr. John Wilson says the 
state of the surface differs in the two forms of the disease — the 
inflammatory and the congestive. " In the former, the heat of 
the skin is high, free, and diffused ; it impresses the hand in- 
stantly and powerfully, being nearly as intense at the extremities 
as at the centre, sometimes even more so. In the latter, the 
heat of the surface is frequently less than in health, particularly 
on the extremities. When it equals or surpasses the healthy 
standard, as it sometimes does, being highest about the epigas- 
trium, it is of a peculiar kind. The hand is scarcely impressed 
by it, when applied lightly and hastily to the pit of the stomach, 
but when kept there with steady pressure, a sensation of deep- 
seated and accumulated heat is communicated. * * * With this 
peculiar condition of the surface as to temperature, there is con- 
nected a peculiar want of tone in the skin, which it is difficult to 
render intelligible by description. It is sometimes dry, harsh, and 
dense; sometimes moist, when a thin, serum-like fluid, or a greasy 
exudation ; sometimes it is smooth, slippery, inelastic, and doughy 
without moisture ; but in whatever manner its functions may be 
perverted or abolished, its characteristic condition is want of 
vitality : when grasped in the hand, and raised from the parts 
beneath, it feels like the skin of one who had ceased to breathe." 1 
The color of the skin will be more appropriately noticed in an- 
other place. 

Sec. III. — Pulse. It is not an easy matter, for one who has 
never felt the pulse of a yellow-fever patient, to form any very 
distinct and clear idea of its character and peculiarities; so con- 
tradictory, and sometimes so apparently fanciful, are the descrip- 
tions of it by different observers. On one point, however, and 
that is, its frequency, there is great uniformity in the statements 
of writers. The pulse never reaches the frequency that is so 
common in nearly all other febrile and inflammatory affections. 
Louis and Trousseau, at Gibraltar, even in cases that terminated 
fatally, never found it higher than a hundred in a minute, and 
this in only five instances, and for a single day. In cases that 
recovered, they generally found it only slightly accelerated, and 

1 Memoirs of West Indian Fever, p. 20. 



462 YELLOW FEVER. 

this for a day or two only, at the beginning of the disease, after 
which it rapidly fell to its natural standard. 1 

As to its other characters, it is commonly described as natural, 
or more or less full, tense, and bounding. In eight fatal cases, 
Louis and Trousseau found it large and vibrating in one ; a little 
stronger than natural in two ; almost natural in two, and small 
and serrated in three. Amongst the patients who recovered, they 
found the pulse large and rather full on the second or third day 
of the disease, in half the cases ; small and feeble during the first 
days, in only two cases ; and natural in the rest. 2 It is generally 
regular, but sometimes unequal and intermittent towards the close 
of the disease. Dr. Rush devotes more than three full pages to a 
description of the pulse, a considerable portion of which descrip- 
tion is not particularly clear or intelligible. He mentions several 
occasional peculiarities of the pulse, such as irregularity, inter- 
mission, preternatural slowness, and so on. He has a great deal 
to say about a small, intermitting, tense, corded, and slow pulse, 
which he thought was peculiar to certain forms of yellow fever ; 
which one of his pupils characterized as an undescribable pulse, 
and which he called a hobbling or a sulky pulse. 3 My personal 
friend and former pupil, Dr. P. H. Lewis, of Mobile, has pub- 
lished, in the first volume of the New Orleans Medical and Sur- 
gical Journal, a valuable and interesting paper on the yellow 
fever of that city, to which I shall have occasion frequently to 
refer. Since the publication of my second edition, our profession 
and our science have sustained a serious loss in the premature 
death of this active, laborious, and able physician. His observa- 
tions were mostly made amidst the hurry and confusion insepa- 
rably attendant upon epidemic visitations of disease, and they 

1 Louis on Yellow Fever, p. 208. 2 Ibid., p. 209. 

3 Dr. Rush, enlightened by the blaze of that luminous philosophy which sur- 
rounds all his medical writings, met with no difficulty in understanding and ac- 
counting for this perverse and unreasonable pulse ; he said it was occasioned by a 
spasmodic affection, accompanied with preternatural dilatation or contraction of 
the heart ! The slow, feeble, and intermittent pulse have been improperly ascribed, 
says Dr. Rush, to the absence of fever. They are occasioned, he adds, "by the 
stimulus of the remote cause acting upon the arteries with too much force to admit 
of their being excited into quick and convulsive motions ;" there being a deficiency 
of strength in the artery from an excess of force applied to it, as Milton describes 
a darkness from an excess of light ! The illustration from Milton is Dr. Rush's 
— not mine. 



SYMPTOMS. — PULSE. 463 

necessarily partake somewhat of the imperfections unavoidable 
under such circumstances ; but they are marked by carefulness, 
acuteness, and conscientiousness, and constitute a valuable addi- 
tion to our knowledge of yellow fever. Dr. Lewis says that, 
during the sort of remission which follows the first febrile reaction, 
and which he calls, after a medical friend, the stage of calm, the 
pulse is usually about or below par, and to many would appear 
natural. "But, so far from being normal," he adds, "there are 
gentlemen in Mobile, who, blindfolded, can separate it from all 
others. It comes up to the finger like an air-bubble, and rebounds 
under the least pressure ; again, there is not that strength and 
lengthened vibrating feeling, which belong to the healthy pulse. 
Dr. Childress, who has been practising in the South thirty-five 
years, remarked to me, that it was the most deceptive pulse he 
had ever felt ; at first appearing natural, but, upon examination, 
there was none of it." This pulse is spoken of by Dr. Lewis, in 
another place, as full and bubbling, compressible and gaseous, 
rebounding under the least pressure of the finger. He says, also, 
that in twenty cases, in which the three stages — the febrile, the 
stage of calm, and that of collapse — were well defined, he found 
the mean range of the pulse, for two days, between 90 and 115, 
for one day about par, and for three and a half days below par ; 
the average range of the pulse during the whole course of the 
disease being rather below the natural and healthy standard. 
This compressible character of the pulse is particularly noticed 
by some of the older writers. Chisholm says : "It is observable 
that, in several cases, the slightest pressure could produce a ces- 
sation of pulse." 1 A sufficiently obvious reason for the contra- 
dictory descriptions which are to be met with, of the pulse in 
yellow fever, may be found in its different characters in the dif- 
ferent forms and stages of the disease. Dr. John Wilson says 
that, in the inflammatory variety, the pulse is remarkable for its 
strength, forcibly repelling the finger, anfl not yielding to ordinary 
pressure. In the congestive form, he says, it is always weak. 
" It offers no resistance to the touch : when the finger is applied 
to an artery, it acts as it would on an inanimate elastic tube half 
full of fluid ; it depresses easily the point on which it bears into 
contact with the opposite point, the contents receding in either 

1 Chisholm's Essay, vol. i. p. 162. 



464 YELLOW FEVER. 

direction. This state of the pulse is so striking and character- 
istic, that I think it can scarcely be overlooked or misappre- 
hended." 1 



ARTICLE II. 

DIGESTIVE AND ABDOMINAL SYMPTOMS. 

Sec. I. — Tongue and Mouth. The tongue is generally moist, 
and more or less coated with a light-colored, whitish, or yellowish- 
white, villous fur. It is sometimes red, and towards the close of 
life in fatal cases, sometimes dry, red, and cracked, like the tongue 
of continued fever. In many instances, it remains nearly natural 
through the entire course of the disease. Dr. Rush says : " The 
tongue was in every case moist, and of a white color, in the first 
and second days of the fever. As the disease advanced, it assumed 
a red color, and a smooth, shining appearance. It was not quite 
dry in this state. Towards the close of the fever, a dry black 
streak appeared in its middle, which gradually extended to every 
part of it." 2 Dr. Gillkrest says, the most characteristic appear- 
ance of the tongue is that of the pasty surface, with red edges 
and apex; and further that the red, or as it has been called by 
some crimson border of the tongue ranks among the most cha- 
racteristic signs in the first stage of the malady. 3 Bally and 
some others, especially amongst Spanish observers, speak of an 
abundant spontaneous salivation as a common occurrence. It is 
rare to find sordes on the teeth. 

Sec. II. — Appetite and Thirst. It is a little singular how 
generally writers upon yellow fever neglect to give any particular 
account of the state of the appetite ; many of them, indeed, make 
no mention of it whatever. Even Louis and Trousseau say nothing 
special about it. Dr. Rush says : " The appetite for food was 
impaired in this, as in all other fevers, but it returned much 
sooner than is common, after the patient began to recover. Coffee 
was relished in the remissions of the fever, in every stage of the 
disease. So keen was the appetite for solid, and more especially 

1 Memoirs of the W. Indian Fever, p. 19. 2 Rush's Med. Inq., vol. iii. p. 63. 
3 Cyc. Prac. Med., vol. ii. pp. 270, 273. 



SYMPTOMS. — APPETITE AND THIRST. 465 

for animal food, after the solution of the fever, that many suffered 
from eating aliment that was improper from its quality or quantity. 
There was a general disrelish for wine, but malt liquors were 
frequently grateful to the taste. Many people retained a relish 
for tobacco much longer after they were attacked by this fever, 
and acquired a relish for it much sooner after they began to 
recover than is common in any other febrile disease. I met 
with one case, in which a man, who was so ill as to require two 
bleedings, continued to chew tobacco through every stage of his 
fever." 1 

The remark that has just been made in regard to the general 
omission by writers on yellow fever of any particular description 
of the state of the appetite is also applicable to the thirst : by 
many, this symptom is not mentioned at all, and by most others, 
it is spoken of only incidentally. It would seem, as a general 
rule, to be only moderate. Dr. Rush says : " The thirst was 
moderate or absent in some cases, but it occurred in the greatest 
number of persons whom I saw in this fever. Sometimes it ^vas 
very intense. One of my patients, who suffered by an excessive 
draught of cold water, declared, just before he died, that lie could 
drink up the Delaware. It was always an alarming symptom, 
when this thirst came on in this extravagant degree in the last 
stage of the disease. In the beginning of the fever it generally 
abated, upon the appearance of a moist skin. Water was pre- 
ferred to all other drinks." 2 Sir Gilbert Blane says there is no 
excessive thirst. 3 Dr. Deveze, in his description of the Philadel- 
phia epidemic of 1793, says that, during the first stage, the degree 
of thirst corresponds to the febrile heat ; and that in the second 
stage it is unappeasable. 4 Bally says there is rarely any con- 
siderable thirst; and he quotes Jackson, Chisholm, and Clark, to 
the same effect. 5 Dr. Lewis of Mobile, in a letter to me, dated 
September 26, 1847, says: " In genuine yellow fever, the thirst 
is not urgent. It is true the patient often says he is thirsty; 
that he wishes he had a cold stream running through him ; but 
when water is handed to him, he drinks very sparingly, saying 
that it lays on his stomach, or produces pain at the epigastrium. 

1 Rush's Med. Inq., vol. iii. p. 67. 2 Ibid., p. 66. 

3 Observations, &c, p. 404. 4 Traite de la Fievre Jaune, p. 22. 

6 Du Typhus d'Amerique. Par Vr. Bally, p. 210. 

30 



466 YELLOW FEVER. 

Others have no desire for cold drinks, but take warm tea without 
objecting." 

Sec. III. — Nausea and Vomiting. Amongst the most constant, 
and in certain circumstances the most striking and characteristic 
phenomena of yellow fever, are nausea and vomiting, especially 
the latter. In a certain proportion of cases, the vomiting occurs 
in the course of the first day of the disease ; in the others, on 
the subsequent days, from the first to the fifth. In cases which 
terminate fatally, the vomiting almost always, after it has com- 
menced, continues to be repeated at longer or shorter intervals 
till the death of the patient ; sometimes, however, the vomiting 
ceases a day or two before death. In cases which terminate in 
recovery, the vomiting usually ceases after having been present 
a few hours only, or from twenty-four to forty-eight hours. The 
matters vomited consist, at first, usually, of the fluids that have 
been taken into the stomach; they then become yellowish or 
greenish, and in patients who recover, they do not generally 
present any other appearances. In cases, however, which are to 
terminate in death, these vomitings soon give way to the well 
known and fatal black vomit. This peculiar and striking symp- 
tom sometimes commences thirty-six or forty- eight hours before 
death; but more commonly not till the last day of life. 1 Louis 
and Trousseau's particular description of the appearances of the 
matter of black vomit, as found in the stomach and intestines, 
will be given in the chapter on the post-mortem phenomena of 
the disease. It is generally described as resembling coffee- 
grounds. Dr. Rush made a distinction, however, between this 
kind of fluid and the true black vomit ; I suppose that the former 
was only the early stage of the latter. Dr. Lewis, of Mobile, 
gives the following account of the gastric symptoms. "As a 
general rule, there are far less vomiting and irritability of stomach 
during the first stage of yellow than that of bilious fever. During 
the stage of calm, a mucus, containing little flocculent masses, 
resembling bees' wings, is sometimes vomited. If bile is ejected, 
it may be set down not only as an exception but a favorable in- 
dication. The black vomit which takes place in the collapse 
stage is of various consistence and appearance. The little 

1 Louis on Yellow Fever, p. 217. 



SYMPTOMS. — BOWELS. — ABDOMEN. — EPIGASTRIUM. 467 

masses, which have been likened to bees wings, occasionally 
deepen, so that, by the time the disease arrives at the collapse 
stage, it assumes the appearance of a thick black mass. The 
vomit is more generally thin and black, with a coffee-ground 
sediment; this is usually pumped up, suddenly, and without pre- 
vious warning; the patient complains of its being sour, and 
so very acrid as to scald the throat. Black vomit, in a few in- 
stances, made its appearance on the night of the second day after 
the attack ; these were exceptions, the fourth and fifth day 
being the most usual ; many cases terminated fatally in which 
this symptom was wanting." 1 Blood but slightly changed is 
sometimes vomited. The easy, sudden, pumping character of the 
act of vomiting, in these cases, mentioned by Dr. Lewis, is spoken 
of by other observers. Several patients, says Louis, appeared to 
vomit without effort, the basin being placed on the edge of the 
bed, and their heads supported on their hands. Dr. Lewis, again, 
in his account of the treatment of yellow fever, remarks incident- 
ally that there are less nausea and retching than in bilious fever ; 
and that " the stomach is frequently disgorged without any other 
symptom than a slight tremulous curl of the upper lip, and a 
consciousness, on the part of the patient, that his stomach is in a 
rebellious mood." 2 Dr. Rush says: " The contents of the stomach 
were sometimes thrown up with a convulsive motion, that pro- 
pelled them in a stream to a great distance, and in some instances 
all over the clothes of the bystanders." 

Sec. IV. — Bowels ; Abdomen; Epigastrium. The bowels are 
generally costive; at least there is rarely any tendency to diar- 
rhoea. The only striking peculiarity in the character of the dis- 
charges consists in their brownish or black color. This symp- 
tom, like the black vomit, is found in a large proportion of the 
fatal cases ; it occurs towards the close of the disease, but on an 
average a little earlier than the black vomit. It depends upon 
the same cause. It occurs also in cases which terminate in reco- 
very, but in a much smaller proportion. 3 

Colicky pains occur in different parts of the abdomen in a cer- 
tain proportion of cases, and during a limited period of time. 

1 N. 0. Med. and Surg. Journ., vol. i. p. 299. 2 Ibid., p. 420. 

8 Louis on Yellow Fever, p. 229, et seq. 



468 YELLOW FEVER. 

They are sometimes occasioned by cathartic medicines; and, ac- 
cording to Louis, their commencement often coincides with the 
appearance of the brown and black stools. The shape and feel 
of the abdomen are nearly always natural, through the -entire 
course of the disease. 

Epigastric tenderness and distress are frequently but not con- 
stantly present. They occur at all periods of the disease. They 
are sometimes severe, but more generally moderate. 1 Dr. Lewis, 
of Mobile, and Dr. John Harrison, of New Orleans, both speak 
of an exquisite tenderness of the epigastrium, occurring chiefly 
towards the close of fatal cases. Dr. Harrison says : " The 
slightest attempt to press upon the parts is resisted by the patient 
with all the expressions of intense agony and horror." The same 
symptom is thus described by Dr. Rush : " The stomach, towards 
the close of the disease, was affected with a burning or spasmo- 
dic pain of the most distressing nature. It produced, in some 
cases, great anguish of body and mind. In others, it produced 
cries and shrieks, which were often heard on the opposite sides 
of the streets to where the patient lay." 2 Bally, and many 
others, mention the same symptoms. 3 According to Dr. Rush, 
flatulence of the stomach is a very constant and in many cases 
a very distressing symptom. 

Sec. Y. — Urine. The urine seems to be, generally, but slightly 
or not at all changed; at any rate, its alterations are accidental, 
and in no way characteristic of the disease. In a certain pro- 
portion of cases, precisely how large, I am unable to say, the 
renal secretion is wholly suspended. This is more frequent in 
fatal cases than in others, although it is not entirely confined to 
them. 4 Bally says that, in the third stage of the disease, the 
urine is very various in its appearance ; sometimes yellow, some- 
times red or bloody, sometimes brown, black, fetid, and so on. 5 

1 Louis on Yellow Fever, p. 212. et seq. 

2 Rush's Med. Inq., vol. iii. p. 66. 

3 Du Typhus d'Amerique. Par Vr. Bally, p. 217. 

4 Louis on Yellow Fever, p. 235, et seq. 

5 Du Typhus d'Amerique. Par Vr. Bally, p. 244. 



SYMPTOMS. — HEADACHE. 469 

ARTICLE III. 

CEREBRO-SPINAL, OR NERVOUS SYMPTOMS. 

Sec. I. — Headache, and other local pains. Pain in the head 
is almost invariably present ; and it is nearly always the first, or 
one of the first signs of the formal access of the disease. It is 
sometimes slight and at others moderate; but more generally, it 
is acute and violent. It is frequently felt through the temples 
and eyeballs. In a few cases it continues through the whole 
course of the disease, but in most instances it subsides in the 
course of two or three days. Pains in the back, loins, and 
limbs are equally constant and equally severe; occurring usually 
with the headache, or immediately following it, and subsiding in 
most cases with the latter. In some instances there are violent 
pains in the calves of the legs. Dr. Rush says: " The back 
suffered very much in this disease. The stoutest men complained 
and even groaned under it. The sympathy of friends with the 
distresses of the sick extended to a small part of their misery, 
when it did not include their sufferings from pain. One of the 
dearest friends I ever lost by death declared, in the height of her 
illness, that no one knew the pains of a yellow fever, but those 
who felt them." 1 Bally speaks particularly of the atrocious pain 
in the small of the back, which accompanies the first stage of the 
disease as the shadow follows the substance. 2 Dr. Lewis says 
that females suffer very little from pain in the head, while it 
is usually very severe in the back and hips ; and that some 
mothers complain of these pains as worse than those of parturi- 
tion. In addition to these acute local pains, which are mostly 
confined to the early period of the disease, the subsequent stages 
of many cases are marked by an indefinite feeling of extreme 
restlessness, wretchedness, and distress, often manifesting itself 
in fits or paroxysms, with longer or shorter intervals of compara- 
tive ease. Dr. Lewis, in reporting a fatal case, has the following : 
" Being asked why he was so restless, he replies that he is not 
restless, neither does he feel very sick ; at the same time, in a 
slow, methodical manner, somewhat peculiar to this disease, he 

1 Rush's Med. Inq., vol. iii. p. 66. 

2 Du Typhus d'Anierique. Par Yr. Ballv, p. 225. 



470 YELLOW FEVER. 

removes the pillow to the other side of the bed, and places his 
head upon it, with the same care and caution as though it were a 
piece of glass. After a few minutes' conversation, the same pre- 
parations are being duly made for a change of position." 1 ' This 
paroxysmal restlessness attends the second and third stages of the 
disease, and constitutes one of its most constant and striking 
features. " Jactitation," says Dr. Gillkrest, " is of more frequent 
occurrence, and more severe in degree, than in any other disease, 
spasmodic cholera not excepted ; the patient tosses his head and 
limbs about incessantly, unable to procure sleep in any position, 
or relief from the feeling of distress by which he is oppressed." 2 
Dizziness and giddiness are rarely mentioned by writers on 
yellow fever. 

Sec. II. — State of the Mind. Delirium is rarely present, ex- 
cepting for a short period, varying from a few hours to a day or 
two preceding death ; it is very rarely wild and violent, and in 
many cases the mind remains clear quite to the close of life. 
"In no other grave malady," says Bally, "do the intellectual 
faculties maintain themselves with such entire integrity as in this ; 
it is a singular phenomenon — that of the presence of mind pre- 
served to the last instant of life." 3 

Dr. Barrington says there is often an inclination to sing ; Dr. 
Lewis says the delirium consists in joking, singing, or idle chit- 
chat; and Dr. Harrison speaks of the little tricks of the patients, 
the kind of perverse pleasure which they manifest in thwarting 
the designs of their nurses and physicians, and their great delight 
at the success of their schemes, as characteristic rather of a spe- 
cies of insanity, than febrile delirium. 

The kind of stolid indifference of patients in this disease has 
often been noticed. The editors of the New Orleans Medical 
Journal say : " It is remarkable to witness the indifference with 
which the victims of yellow fever in the Charity Hospital seem to 
view death. The large congregation of sick and dying seems to 
render them familiar with his face, and to rob him of more than 
half his terrors. After entering the hospital, and witnessing the 
dying struggles of some half dozen or a dozen fellow-sufferers, 

1 N. 0. Med. and Surg. Journ., vol. i. p. 296. 

2 Cyc. Prac. Med., yol. ii. p. 270. 

3 Du Typhus d'Amerique. Par Vr. Bally, p. 211. 



SYMPTOMS. — PHYSIOGNOMY. 471 

they meet their fate with composure, and quietly resign a life 
which, perhaps, to many of them, had presented naught but a 
varied scene of toil and care." 1 Dr. Rush, and Dr. Lewis, of 
Mobile, speak of occasional cases, not attended with delirium, 
in which the patients after recovery retain no recollection of 
what took place during their illness. 

Coma is an uncommon symptom ; but sometimes grave cases 
are marked by different degrees of drowsiness and stupor. The 
sleep is generally disturbed, and the patients often harassed by 
distressing dreams. 

Sec. III. — Physiognomy. The appearance of the face, and 
the expression of the countenance, have always been particularly 
noticed by observers of yellow fever. Dr. Rush says : " Upon 
entering a sick room, where a patient was confined by this fever, 
the first thing that struck the eye of a physician was the counte- 
nance. It was as much unlike that which is exhibited in the 
common bilious fever, as the face of a wild is unlike the face of a 
mild domestic animal. The eyes were sad, watery, and so in- 
flamed, in some cases, as to resemble two balls of fire. Some- 
times, they had a most brilliant or ferocious appearance. The 
face was suffused with blood, or of a dusky color, and the whole 
countenance was downcast and clouded." 2 Mr. Pym says, it is 
impossible to describe the appearance of the face, but that those 
wishing to form an idea of it may see what he calls its fac- simile 
in the countenance of any person with a florid complexion, dur- 
ing the burning of spirit of wine and salt, in a dark room, as is 
practised in the game of Snap Dragon during the Christmas Gam- 
bols. 3 Dr. Lewis, of Mobile, says : "The physiognomy of the 
disease is striking and peculiar. I have not noticed, however, 
any of that wild, ferocious expression of eye and features which 
is spoken of by many writers. There is usually an attempt on 
the part of the patient to appear amiable and indifferent, seldom 
becoming peevish, or losing temper. The expression of which 
I am speaking is, in many cases, stamped upon the brow at an 
early period ; and, 'once enthroned,' no effort of the patient can 
disturb its reign ; — he may smile and laugh, but he cannot chase 

1 N. 0. Med. and Surg. Journ., vol. i. p. 77. 

2 Rush's Med. Inq., vol. iii. p. 52. 3 Pym upon Bulam Fever, p. 5. 



472 YELLOW FEVER. 

it away ; there it still sits, mocking the assumed gayety and levity 
of its victim. Even the cradle is not exempt from its visitations ; 
within the last hour, I have seen a child, but fifteen months old, 
over whose brow this mysterious fiend has spread its gloomy 
mantle, giving to the little patient a dejected, cheerless, and 
earnest look, ill suited to its infant face." 1 

Dr. John Wilson, in a report of a case of what he calls apo- 
plectic congestive yellow fever, speaks of a peculiar smile seen at 
times on the patient's face, and then adds, in a note : "It would 
be difficult to give a just notion of this peculiar smile to a person 
who has not seen it. Unlike the smile of health and happiness, 
it is confined to the mouth ; the face generally, and the eye in 
particular, having no share in its expression, but rather counter- 
acting or contradicting it, by their fixedness and despondency : 
neither has it any of the hideousness and distortion of the risus 
Sardonicus. It is a quiet, transient, smiling movement of the 
lips alone, melancholy in itself, and by contrast with the general 
aspect ; and rendered more melancholy, by being associated with 
apprehensions of a fatal issue ; for in my observation it has always 
been the forerunner of death." 2 

The redness and suffusion of the eyes, so striking in this dis- 
ease, and noticed by nearly all writers, have been particularly de- 
scribed by Louis. He found them in all cases, the mild as well 
as the severe ; and they were generally present at the commence- 
ment of, or early in, the disease. In cases terminating fatally, 
the redness of the eyes sometimes continues undiminished to the 
close of life ; more generally it becomes less intense, or disap- 
pears, before death. In cases terminating in recovery, it disap- 
pears with convalescence and the patient's restoration to health. 
In most instances, the redness had a double character — a uniform, 
delicate rose tint, as if put on with a brush, and a more or less 
marked injection of the vessels of the conjunctiva. " In the cases 
where the redness had not disappeared at the time the yellowness 
came on, the mixture of yellow and red in the sclerotic was very 
remarkable. The eyes were usually more or less glistening, moist 
and suffused, frequently sensible to the light, but rarely what may 
be called painful." 3 Sir Gilbert Blane says: "There is some- 

1 N. 0. Med. and Surg. Journ., vol. i. p. 299. 

2 Memoirs of the West Indian Fever, p. 57. 

3 Louis on Yellow Fever, p. 200. 



SYMPTOMS. — STRENGTH. — MUSCLES. — SENSES. 473 

thing very peculiar in the countenance of those who are seized 
with this fever, descernible from the beginning, by those who are 
accustomed to see it. This appearance consists in a yellow or 
dingy flushing or fulness of the face and neck, particularly about 
the parotid glands, where the yellow color of the skin is commonly 
first perceived. There is also in the eye and muscles of the 
countenance a remarkable expression of dejection and distress." 1 

Sec. IV. — Strength ; Muscles ; Senses. In a certain propor- 
tion of cases, there is more or less loss or prostration of muscular 
strength. Sometimes, and especially when there is much hemor- 
rhage, this may be extreme ; but it is more commonly only mo- 
derate, and, in many instances, it is absent to a very striking 
degree. Dr. Rush says : "Patients in the close of the disease 
often rose from their beds, walked across their rooms, or came 
down stairs, with as much ease as if they had been in perfect 
health. I lost a patient in whom this state of morbid strength 
occurred to such a degree, that he stood up before his glass and 
shaved himself on the day upon which he died." 2 These are 
called ivalking cases by the physicians of our Southern cities. 3 
Although they are exceedingly grave in their character, almost 
always terminating fatally, they are not generally marked by the 
usual symptoms of the disease. There may be no chill, no fever, 
no local pain ; and the tongue, pulse, and skin arc nearly natu- 
ral. These singular latent cases are noticed also by Louis. "It 
is under this form of the disease," he says, "that patients died 
without taking to their beds ; on foot, as it was expressed by their 
friends. Thus, Dr. Mathias, who died after an illness of four or 
five days, experienced no other symptoms but severe pains in the 
calves of the legs, and a suppression of urine. He had no nau- 
sea ; he did not vomit. His mind was perfectly clear, during the 
whole course of the disease ; he noticed the continuance of the 
suppression of urine, dictated three or four letters to a friend, 
begged him to write rapidly the last, so that he might sign it, 
then devoted a little time to an affectionate intercourse with this 
friend, and soon after, unable to speak, he thanked the friend 

1 Obs. Dis. Seamen, p. 400. 3 Rush's Med. Inq., vol. iii. p. 64. 

2 This term is said to have been first applied to these cases by Professor Cald- 
well, now of Louisville, Kentucky. 



474 YELLOW FEVER. 

by a sign, and in a quarter of an hour lie was dead." 1 " I have 
known a man," says Dr. John Wilson, " in cases like these, ordered 
to do his duty, because the surgeon could not perceive much the 
matter with him ; he continued to do his duty, after a fashion, for 
nearly two days, when the eruption of black vomit gave irresisti- 
ble and mortifying evidence that the man was no impostor." 3 
Spasmodic contractions of the muscles are of rare occurrence ; 
excepting, however, those of the diaphragm, constituting hiccough. 
This is a frequent and very sure precursor of death. 

The senses are generally free from any considerable disturb- 
ance. Slight intolerance of light is not unfrequently present. 
The hearing is unimpaired, and there is not often any ringing in 
the ears. 



AKTICLE IV. 

MISCELLANEOUS SYMPTOMS. 

Sec. I. — Color of the Shin. Yellowness of the surface of the 
body is almost always present in fatal cases ; occasionally it is 
wanting. Sometimes it appears early in the disease, but in most 
instances not till about the middle period, or later. The yellow- 
ness is often deeper on the chest than upon other parts of the 
body; and it is frequently preceded by a more or less vivid red- 
ness and injection of the integuments. It usually shows itself 
first on the conjunctiva, and round the border of the chin, then 
extending to the chest, and afterwards over the body. In mild 
cases, and in those terminating in recovery, this symptom is very 
frequently absent. Dr. Bancroft says : " The yellowness is some- 
times of a dingy or brownish hue, sometimes of a pale lemon, 
and at others of a full orange color." 3 Dr. Gillkrest says the 
yellowness may be partial or general, and may vary from the 
light lemon color to deep ochre yellow. 4 Dr. John Wilson says 
the discoloration of the skin differs in the two forms of the dis- 
ease — the inflammatory and the congestive. " In the former, 
the skin is yellow, of different shades in different instances. 
Sometimes it is light, sometimes dark; sometimes it is of the color 

1 Louis on Yellow Fever, p. 170. 2 Memoirs of the West Indian Fever, p. 15. 
3 Bancroft's Essay, p. 34. 4 Cyc. Prac. Med., vol. ii. p. 273. 



SYMPTOMS. — HEMORRHAGES. 475 

of an unripe lime, sometimes of a mellow orange; varying con- 
stantly, and being scarcely the same, in every respect, in any 
two cases : still, it is yellow, and would be instantly pronounced 
so by all observers ; though in endeavoring to describe its exact 
tinge different words would be employed by different persons, 
sometimes inappropriate ones, and erroneous opinions would 
thence be formed. * * * In the congestive form, the skin is dis- 
colored, but does not become yellow. Its color is not like that 
of an icteric patient; it may rather be called petechial, as it 
resembles though it is not exactly like the skin of persons in the 
last stage of what is called putrid fever. From the first, the 
skin loses its proper lustre. It becomes blanched, or lurid ; and 
as the disease advances, livid and black patches of various sizes 
are observed on the breast, back, hips, scrotum, and extremities. 
They pervade the surface, but are most numerous generally on 
the trunk. About their margins there is a yellowish or greenish 
hue, either of them indistinct, and what is called dirty. It is 
difficult to describe the aspect of the skin accurately and intelli- 
gibly ; but by comparing it with a familiar object which it very 
closely resembles, a pretty correct notion of its peculiarities will 
be obtained. When yellow leather gloves are worn on horse- 
back, in rainy weather, and the glove of the bridle hand is tho- 
roughly wet, the palm part of it exhibits a very just likeness of 
what I have attempted to delineate — turbid white, and livid or 
black, intermixed with imperfect margins of yellow and green, or 
a hue in which yellow and green are blended, and it is difficult to 
say which predominates. This appearance of the skin in the 
congestive form, and the yellowness which I have appropriated to 
the inflammatory, I am persuaded, are characteristic of each re- 
spectively ; but I am not from my experience justified in saying 
they are so absolutely, and without any exception." 1 

Sec. II. — Hemorrhages. Nearly all writers upon yellow fever 
speak of the frequency of hemorrhages from different parts of the 
body. Dr. Rush, after mentioning the occasional occurrence of 
bleeding from the nose, and from the uterus, in the early period 
of the fever, says : " As the disease advanced the discharges of 
blood became more universal. They occurred from the gums, 

1 Memoirs of the West Indian Fever, p. 22. 



476 YELLOW FEVER. 

ears, stomach, bowels, and urinary passages. Drops of blood 
issued from the inner canthus of the left eye of Mr. Josiah Coates. 
Dr. Woodhouse attended a lady who bled from the holes in her 
ears, which had been made by ear-rings. Many bled from the 
orifices which had been made by bleeding, several days after they 
appeared to have been healed. These last hemorrhages were very 
troublesome, and in some cases precipitated death." 1 Similar 
bleedings are spoken of by other writers, from blistered surfaces, 
from the scrotum, from the uterus, from mosquito-bites, from leech- 
bites, and so on. They take place more frequently from the gums 
and tongue than from any other part of the body ; and there is 
good reason for believing that these last are occasioned, in part 
at least, by the action of mercurials. Hemorrhages are more com- 
mon in the latter stages of grave cases, than under other circum- 
stances ; and they seem to be more general in some seasons and 
places than others. By many pathologists, the matter of black 
vomit, and of the black stools, is considered to be the result of a 
true hemorrhage from the gastro-intestinal mucous surface. 

Sec. III. — Chest. The symptoms connected with the lungs 
are quite unimportant and accidental. There is no cough, and 
there are no morbid rhonchi. The breathing in the late stages of 
grave and fatal cases is not unfrequently more or less deep, and 
sighing. I do not know that the action of the heart has been 
particularly studied. 

1 Rush's Med. Inq,, vol. iii. p 57. 



477 



CHAPTER III. 

ANATOMICAL LESIONS. 

ARTICLE I. 

LESIONS OF THE LUNGS, HEART, AND BLOOD. 

Sec. I. — Lungs. The condition of these organs, so far as I 
know, has been particularly and carefully studied only by Louis 
and Trousseau; and in fifteen cases they found them the seat of 
lesions which seem to have been very rarely met with in any 
other disease. These lesions consisted of black spots of from two 
to five lines in diameter, or of masses of the same color more or 
less impermeable to the air. The spots were found in nine sub- 
jects. In a few causes they were of a crimson hue, but gene- 
rally they were brown or black. They were more or less crowd- 
ed together, occupying a space of variable extent on the surface 
or in the interior of the lung ; in some cases, they were found 
only in the lower lobe. The density of the tissue which was the 
seat of them was not manifestly increased, except in two cases : 
this increase of density was evidently the result of an effusion of 
blood, more or less intimately combined with the pulmonary 
tissue. " The black or blackish masses existed in six individuals ; 
their consistence was greater or less ; they contained no air ; they 
had not the granulated aspect of hepatized lung; they presented 
but slight traces of organization, so that merely some cellular 
fibres irregularly disposed could be distinguished in them. 
Usually, they could be easily broken down; in some cases, also, 
they yielded by pressure the blood of which they were almost 
entirely composed, and the pulmonary parenchyma remained 
apparently of its natural consistence. In one case it was impos- 
sible to remove the blood by a gradual and moderate pressure, 
and here the tumor or mass was as large as the fist, had more 
cohesion than the parts in the second degree of pneumonia, and 



478 YELLOW FEVER. 

less than the parts in the state which the illustrious Laennec has 
designated as pulmonary apoplexy. The same was true in 
another subject, in whose lungs were found from twenty-five to 
thirty tumors of this same character, though of a little different 
aspect, and somewhat resembling the thyroid gland. Their 
structure was apparently homogeneous, quite friable, and as in 
the other cases, there was no line of demarcation between them 
and the pulmonary tissue." I do not know whether it was this 
lesion of the lungs that was noticed by Arejula at Cadiz in 1800. 
He says: "On opening the cavity of the thorax, the lungs 
appeared speckled with black and gangrenous spots, which were 
particularly observed in those bodies in which the disease had 
assumed the most malignant form. 1 Mr. M'Colme says: u The 
lungs were often blackish next the pleura, and interspersed in 
many places with large livid spots." 2 Dr. Deveze seems to have 
studied the anatomical lesions of yellow fever, during the Phila- 
delphia epidemic of 1793, with more zeal and carefulness than 
any other physician. He does not state the number of his autop- 
sies, but he reports in detail eight examinations which he made 
at the Bush Hill Hospital. The lungs, he says, were sometimes 
found healthy; but more frequently they were flabby, covered 
with black spots, engorged with blood of the same color, and so 
on. He quotes other observers who had noticed black and gan- 
grenous spots on the surface of the lungs. 3 O'Halloran did not 
notice any special alteration of these organs. Louis and Trous- 
seau found, in several cases, a livid color of the air-passages, 
more or less vivid, occupying the mucous and the sub-mucous 
cellular tissue. Other lesions of the lungs and pleurae are of 
very rare occurrence. 4 

Sec. II. — Heart. Louis and Trousseau found the heart soft or 
flabby, or both soft and flabby, in a considerable proportion of 
cases. Other changes in this organ, and in the aorta, are acci- 
dental merely, and such as are frequently found after death from 
acute disease. Deveze found the heart flabby, pale, and very 
soft. 5 

1 Reports, etc., by Sir J. Fellowes, p. 68. 2 Hunter's Dis. of Army, p. 161. 

3 Traite de la Fievre Jaune. Par Jean Deveze, p. 62. 

4 Louis on Yellow Fever, p. 63, et seq. 6 Rush's Med. Inq., vol. iii. p. 92. 



LESIONS. — BLOOD. 479 

Sec. III. — Blood. The blood found in the cavities of the 
heart, and in the large vessels, after death, seems to be very 
generally changed from its natural condition. This change was 
noticed by the older observers ; and it has been more particu- 
larly studied in our own time. Dr. Physick and Dr. Cathrall 
say : " The blood in the heart and veins is fluid, similar in its 
consistence to the blood of persons who have been hanged, or 
destroyed by electricity. 1 Hillary speaks particularly and re- 
peatedly of the state of the blood. " Even at the beginning of 
the disease," he says, " it is often of an exceeding florid red color, 
much rarefied and thin, and without the least appearance of sizi- 
ness ; and the crassamentum, when it has stood till it is cold, will 
scarce cohere, but fluctuates." 2 Louis and Trousseau found the 
blood generally either liquid only, or liquid and clotted ; the clots 
being black, or yellow, and fibrinous. Dr. Nott, of Mobile, 
gives the following interesting account of the blood in the cases 
examined by him, in 1843 and 1844. " This was found dark 
and fluid in every case where the bodies were opened. Minute 
observations were not made, in all the cases, but in about one- 
half, the blood was collected by thrusting a trocar into the right 
auricle, and drawing it off into clean quinine bottles. It was so 
fluid, and was accumulated in such quantity in the auricle and 
veins connected with it, that, ten or twelve hours after death, it 
would run freely through the canula, to the amount of a pint or 
more. When set aside, it coagulated at intervals, varying from 
fifteen or twenty minutes, to thirty-six hours ; the clots were soft, 
grumous, easily broken down, showing a great deficiency of 
fibrine, and corresponding with Andral's description of the blood 
in the other pyrexiae. In one case, it did not coagulate at all, 
but presented a true state of dissolution." 3 Dr. Harrison says 
it requires a much longer time for the blood to coagulate than in 
other diseases, and that the coagulum is large and soft ; he adds, 
that it rarely presents the buffy coat when drawn from the arm, 
and that he has never seen it cupped. 4 

1 Eush's Med. Inq., vol. iii. p. 92. 2 Rush's Hillary, p. 108. 

3 Am. Journ. Med. Sci., April, 1845. 

4 N. 0. Med. and Surg. Journ., vol. ii. p. 140. 



480 YELLOW FEVER. 

ARTICLE II. 

LESIONS OF THE CEREBRO-SPINAL APPARATUS. 

There are no alterations of this apparatus, excepting such as 
are frequently found after death from other acute diseases. These 
are moderate effusions of serum in the sub-arachnoid tissue and 
into the cavities of the brain ; a more or less red, or violet, or lilac 
color of the cortical substance, and occasional slight injection of 
the medullary portion of the brain. 

ARTICLE III. 

LESIONS OF THE ABDOMINAL ORGANS. 

Sec. I. — Stomach. The mucous membrane of the stomach is 
more or less altered in a pretty large proportion of cases. Louis 
and Trousseau found it of natural thickness, consistency, and 
aspect, with the exception only of slight changes of color in five, 
of twenty-three cases ; in the remainder it presented evident 
traces of previous inflammation. Its color was quite natural in 
only three cases ; in several it was more or less deeply red, some- 
times over its whole surface, and at others only over circumscribed 
portions ; in eight cases, instead of a red color, there was an orange, 
or a slight rose tint, or a color of onion parings, varying in ex- 
tent ; in two cases there was a ruddy or bistre hue, and in two 
others the membrane was greenish or yellowish. The thickness 
of the membrane was natural in half the cases ; in the other half 
the thickness was increased ; in some universally, and in others 
partially. Its consistence was natural in only two subjects, in 
all the rest it was more or less diminished. The softening was 
general but moderate in five ; partial and but rarely to a remark- 
able degree in the others, so that in no region, not even in the 
great cul-de-sac, was the membrane reduced to the consistence 
of mucus. Well marked and more or less extensive mamellona- 
tion was found in two-thirds of the subjects ; and it is important 
to remark that this lesion was always accompanied by thickening, 
or softening of the membrane, or by both, and by alterations of 
its color. Dr. Ashbel Smith has published a history of the appear- 
ance of the abdominal organs in seven cases of yellow fever, 



LESIONS. — STOMACH. — CONTENTS. 481 

occurring in Galveston, Texas, in 1839. He found the mucous 
membrane of the stomach of a whitish pearl color, much thick- 
ened and softened. In four cases, these lesions were limited to 
certain portions of the membrane, while the remaining portion, 
in the cardiac extremity, was the seat of a very intense, uniform, 
red injection, but was neither thickened nor softened. 1 Subse- 
quent observations, by other physicians, have led to the same 
general results, in regard to the condition of the stomach. Dr. 
Josiah C. Nott, of Mobile, in sixteen cases, examined in 1843 
and 1844, found the mucous coat of the stomach free from any 
appreciable change in seven ; in the remaining nine it was more 
or less reddened, softened, thickened, and mamellonated. 2 

The contents of the stomach are thus minutely and particularly 
described by Louis. In four subjects, the stomach contained 
only a small quantity of flocculent mucus, or a little grayish, 
yellowish, or dark-colored liquid ; in all the others, eighteen in 
number, the contents of the stomach were red, more or less in- 
clining to black. This red or black matter varied in quantity, 
from four to twenty ounces ; and its quantity was in proportion 
to the depth of the red color ; the mean quantity where the color 
was bright red being nine ounces, and fourteen ounces where it 
was entirely black. The consistence of the red and the black 
matter was about the same; in some it was quite liquid, in others 
it was like porridge. It separated on standing into two portions ; 
the upper more liquid than the lower, and of a bistre color ; the 
lower less abundant, and formed as it were of blackish parcels. 3 
This matter of black vomit was formerly supposed to be derived 
principally from the liver, and to consist of vitiated bile, mixed 
with the fluids of the stomach. Dr. Rush says that he at one 
time believed this matter to consist of vitiated bile, but that sub- 
sequent dissections by Dr. Stewart and Dr. Physick, convinced 
him that it was derived from the stomach ; although I find in the 
report of the dissections, made by Dr. Physick and Dr. Cathrall, 
and quoted by Dr. Rush, the black liquor found in the stomach 
and intestines referred to an altered secretion from the liver. 
This opinion is now, I think, generally if not universally aban- 
doned ; and it seems to me quite clear that the matter of black 

1 Araer. Journ. Med. Sci., Feb. 1840. 2 Ibid., April, 1845. 

3 Louis on Yellow Fever, p. 79, ei scq. 

31 



482 YELLOW FEVER. 

-vomit consists of blood, mixed with the fluid secretions of the 
stomach, and derived directly from the mucous membrane. Dr. 
Nott, and Dr. P. H. Lewis, of Mobile, have made some interest- 
ing experiments for the purpose of ascertaining the nature of this 
substance. Dr. Nott believes it to consist of blood, exhaled in 
its natural state from the capillaries of the stomach, intestines, 
and even the bladder, and changed black by the secretions with 
which it comes in contact ; this chemical change being produced 
by one or more acids. He says that the matter of black vomit is 
always acid, turning litmus paper red ; and he supposes that the 
acrid property of the liquid may depend upon the presence of these 
acids. Dr. Nott found, further, that the matter of black vomit 
can be very exactly imitated, by adding to a few drachms of blood 
four or five drops of muriatic acid, and a little gum water, or flax- 
seed tea, to represent the mucus of the stomach. No one can 
distinguish, he says, the artificial from the natural black vomit ; 
although he admits that the small coffee-grounds coagula are 
more difficult to imitate. A very small quantity of blood, he 
thinks, oozing gradually in a minutely divided form, and ming- 
ling slowly with the secretions of the mucous membrane of the 
stomach and bowels, will make a large quantity of black vomit. 1 
The opinion that the coloring matter of black vomit consists of 
blood, is strengthened by the fact that, in some instances, pure 
blood is found in the stomach. It is probable that, as a general 
rule, this matter is derived exclusively from the mucous surface 
of the stomach, and not from that of the intestines; although 
the observations of Louis lead to the conclusion that it may 
sometimes be furnished by the latter. It is important that a 
single additional remark should be made here. We have no right 
to assume that the appreciable inflammatory lesions of the 
stomach are the essential cause and condition of the presence of 
the matter of black vomit; and this for the obvious reason that 
the latter is not unfrequently found where the former do not 
exist. All that we can do in the present state of our knowledge 
is to refer the productions of this substance to some special but 
unascertained pathological action or condition of the mucous 
membrane of the stomach, or of the fluids of the body; or, as is 
more probably true, of both; the inflammatory lesions of the 

1 Amer. Journ. Med. Sci., April, 1845. 



LESIONS. — STOMACn. — INTESTINES. 483 

gastric mucous membrane being also one of the results and com- 
plications of this same action or condition. 1 

As to the nature of these lesions of the stomach, it seems to me 
there can be no reasonable doubt. Where they are well marked, 
and especially where the membrane is reddened, softened, and 
mamellonated, we are obliged to consider them the result of in- 
flammation. If we refuse to do this, merely because some of the 
ordinary phenomena of simple acute gastritis are wanting, there 
is at once an end to all rational or positive conclusions. At the 
same time it must be admitted that the inflammation of the gas- 
tric mucous surface is a peculiar or specific inflammation ; it is 
in some way modified by the general disease ; it derives from the 
latter some special and unknown element, which does not exist 
in other forms of gastritis, whether these latter are primary or 
secondary. 

Dr. Ashbel Smith concludes from his observations, that the 
softened, thickened, and mamellonated condition of the membrane 
is always preceded by an intense sanguineous engorgement, dif- 
fering in its nature from inflammation, and resulting in the pro- 
duction of the matter of black vomit, and the lesions of the mem- 
brane which it precedes. 2 

Ulceration is of very rare occurrence. In regard to the volume 
of the stomach there is nothing constant : sometimes it is con- 
tracted, sometimes distended, and at others natural. 

Sec. II. — Intestines. The mucous membrane of the small in- 
testines is, in a considerable number of cases, quite natural 

1 The true character and origin of the matter of black vomit were clearly stated 
a long time ago. Dr. Bancroft quotes Dr. Henry Warren, who -wrote on the yellow 
fever of Barbadoes, in 1740. Dr. Warren says: "I ought here to observe, that 
the fatal black stools and vomitings are vulgarly supposed to be only large quan- 
tities of black bile or choler, which false notion seems to be owing to that fixed 
unhappy prejudice that the fever is purely bilious. But let any one only dip in a bit 
of white linen cloth, he will soon be undeceived, and convinced that scarce any- 
thing but mortified blood is then voided, for the cloth will appear tinged of a deep 
bloody red, or purple, of which I have made many experiments." — Bancrofts 
Essay, p. 28. Sir John Pringle, Dr. John Hunter, and Sir Gilbert Blane, amongst 
others, entertained similar views. Mr. Pyni says he is convinced that the matter 
of black vomit is blood in a dissolved state, poured forth from the small vessels, 
abraded by the separation or disease of the villous coat, and acted upon by the 
gastric fluid. 

2 Anier. Journ. Med. ScL, Feb. 1840. 



484 YELLOW FEVER. 

throughout its whole extent ; or it is the seat only of slight and 
unimportant alterations. Its thickness and consistence are rarely 
changed; in a certain proportion of cases there are patches or 
sections of redness, mostly within a few feet of the coecum. 
Redness, softening, and thickening of the lining of the large 
intestine are more frequent. Louis and Trousseau found uni- 
versal softening in fourteen of twenty-three cases. The latter 
lesions are probably the result of inflammation. 

The upper portion of the small intestine usually contains the 
same kind of reddish, brownish, or blackish matter that is found 
in the stomach ; and the same substance is found also in the large 
intestine. 1 It is thicker and more consistent especially in the 
large intestine than it is in the stomach. Pure blood has occa- 
sionally, though rarely, been found both in the stomach and 
bowels. The volume of the intestines is not often altered. 

Louis and Trousseau found the epidermis which lines the 
oesophagus perfect in only five cases ; in all the others it was 
more or less completely destroyed. 2 Dr. Nott of Mobile thinks 
it probable that this destruction of the epidermis of the oesopha- 
gus depends upon the acid acridness of the matter of black 
vomit. 3 

Sec. III. — Liver. Since the publication of the researches of 
Louis and Trousseau upon the yellow fever of Gibraltar, in 1828, 
the attention of pathologists has been turned particularly to the 
condition of the liver in this disease ; and the result of subsequent 
observations in regard to the state of this organ in periodical, or 
marsh fevers, has imparted to the subject new interest and im- 
portance. The following, I believe, is a full and fair summary 
of the present state of our knowledge in relation to this question. 

Louis and Trousseau, in all the subjects examined by them at 
Gibraltar, found a very striking and uniform change in the color 
of the liver. They describe the liver as being sometimes of the 
color of fresh butter ; sometimes of a straw color ; sometimes 
of the color of coffee and milk ; sometimes of a yellowish gum 
color, or a mustard color, and, finally, sometimes of an orange or 
pistachio color. "This discoloration/' they say, "was not the 

1 Amer. Journ. of Med. Sci., Feb. 1840. 

2 Louis on Yellow Fever, p. 100, et seg. 

3 Nott on Path, of Yellow Fever. 



LESIONS. — LIVER. 485 

same throughout the whole extent of the liver; more marked in 
the left than in the right lobe ; it was also more uniform. In cases 
where the color was uniform in the left lobe, there was in the 
right lobe a mixture of gum yellow, orange, or red points, larger 
or smaller; or else we found in the right lobe a rose tint, which 
did not exist in the left lobe. The cases in which the color of 
the liver was formed by the mingling of different colored points 
were rare; and this disposition was somewhat remarkable in one 
of them, where the liver presented a mixture of yellow and green 
points. This change of color extended throughout the whole of 
the organ, in all but three cases ; in these, it was limited to the 
left lobe, or to the left and a part of the right, the latter preserving 
its natural color throughout, or in its obtuse edge only." 

"With the discoloration of the liver, are found a more or less 
marked paleness, and a diminished quantity of blood, so that 
wherever this appearance of the liver was well marked, the sec- 
tions of it were dry, and of an arid appearance in the left lobe. 
This appearance reminded us at first of the greasy transformation 
of the liver, a transformation always accompanied by a softening, 
more or less marked. In the cases now under consideration, the 
cohesion of the liver was not at all diminished, even where the 
organ was of a clear coffee and milk color, or of a straw yellow, 
or of the color of sole leather." 1 The cohesion of the liver, and 
the resistance of its tissue to the knife, or to the hand, on at- 
tempting to break it, were increased in five cases, and diminished 
in five others. 

The singular change in the color of the liver, thus particularly 
and specially studied by Louis and Trousseau, is regarded by the 
former as the characteristic anatomical lesion of yellow fever — the 
only lesion constantly found after death from this disease. Louis's 
conclusion, so far as his own facts are concerned, and he carries 
it no further, is legitimate ; but these facts were not sufficiently 
numerous and various, finally and definitively to determine the 
question. These facts were gathered in a single locality, and 
during the same epidemic season ; and although analogies drawn 
from some other forms of fever, and especially from typhoid, might 
seem to favor the probability, or in some degree to justify the 
conclusion that this lesion of the liver would prove to be constant 

1 Louis on Yellow Fever, p. 117, et scq. 



486 YELLOW FEVER. 

and characteristic, still, such analogies are never to be trusted, 
and the settlement of the question must be referred to further and 
more extensive observations. But before giving the results of these 
observations, so far as they have jet been made, it may not be 
wholly without interest to notice some of the allusions to the con- 
dition of the liver made by the older writers upon yellow fever ; 
from which it appears that this change of color had not entirely 
escaped their notice, although they generally describe the organ 
as natural or congested, corrupted, and so on. "Dr. Hume," 
says Dr. Rush, "in describing the yellow fever of Jamaica, in- 
forms us that, in several dead bodies which he opened, he found 
the liver enlarged and turbid with bile, and of a pale yellow 
color. ,n Dr. Chisholm made five autopsies', in the yellow fever 
of the West Indies, towards the close of the last century, and he 
describes the liver as being u of a color nearly approaching to 
buff, or a mixture of yellow and that of ashes.'' 2 Arejula, in his 
account of the yellow fever of Cadiz, in 1800, says: "In many 
subjects the liver was enlarged, and its consistence so much 
altered as to appear as if it had been macerated; and this organ, 
as well as others, was found tinged of a different color, approach- 
ing to the hue between yellow and black." 3 Dr. Rand and Dr. 
Warren, in their account of an autopsy made in Boston in 1798, 
describe the liver as appearing to be much inflamed, both on its 
convex and concave surface; its substance much indurated, and, 
on cutting, resembling in color a boiled liver. Mr. John M'Colme, 
whom John Hunter calls a man of veracity and observation, and 
who served as a regimental surgeon in the West Indies, in the 
years 1741 and 1742, has given an account, in a letter to Sir John 
Pringle, of the appearances on dissection in the bodies of twenty- 
three officers and soldiers, who died with yellow fever. He begins 
his letter in these words: " In all the cases, the liver was changed 
in part, and sometimes almost the whole — to be more pale and 
hard than natural ; and, in such parts, there was a less proportion 
of blood than in those of a more natural color." 4 

Dr. Burnett reports a case in which the substance of the liver 
was of a yellow color ; and he quotes from Mr. Whitmarsh the 

1 Rush's Med. Inq., vol. iii. p. 91. 2 Chisholm's Essay, vol. i. p. 183. 

3 Reports, etc. by Sir J. Fellowes, p. 68. 4 Hunter's Dis. of Army, p. 60. 



LESIONS. — LIVER. 487 

account of two cases of the Gibraltar fever of 1813, in which the 
liver was found of an ash color. 1 

Mr. Doughty has published, quite in detail, the appearances on 
dissection in eight cases, examined at Cadiz, in 1810. In some, 
the liver is called natural; in some, dark and engorged; in one, 
the color is described as between a light and dark yellow ; and in 
one, as a light yellow. 2 Dr. Hume made some examinations be- 
fore the middle of the last century. He says: "The liver which 
is naturally of a dark red color, frequently appears on dissection 
in the yellow fever to be pale and yellow"* 

The observations of O'Halloran upon this point, made in 1821, 
are very interesting. In his first reported case, the liver is de- 
scribed as extremely yelloiv externally, hard and dense when cut 
into ; the flow of blood inconsiderable ; in the second, the liver 
was yellow, hard, and deficient in blood; in the third, hard and 
yellow, tvithout blood; in the fourth, thick, hard, compacted, dry 
and pale, ivith no flow of blood when cut into, and crumbling be- 
tween the fingers; in the fifth, pale externally, hard to the feel, 
internally destitute of blood, and gritty, so as to be easily crum- 
bled into small pieces; in the sixth, large and hard, crumbling 
bettveen the fingers ; in the eighth, pale yelloiv externally, inter- 
nally hard, destitute of blood, and easily broken into small pieces ; 
and in the ninth, considerably enlarged, hard and yellow exter- 
nally, internally destitute of blood, and easily crumbled. In 
three cases, it is described as either healthy, or inflamed. He 
quotes a letter from Dr. Salvador Campany, who says : u The 
liver presented a saffron color, sometimes with obscure stains in 
its concave part." 4 

Dr. Nott, of Mobile, in his interesting paper on the Pathology 
of Yellow Fever, describes the liver as it appeared in sixteen 
cases of the disease. Of eight cases examined during the epi- 
demic of 1843, the livers in two only corresponded with the de- 
scription of Louis, being pale, and when torn resembling very 
closely gingerbread, or neiv leather ; in the six others, the liver 
was of a dark blue or a dark chocolate color, presenting different 
shades, and excessively engorged with blood. Of eight cases 
examined in 1844, the liver in four corresponded with the de- 

1 Burnett, p. 306. 3 Currie's Dis. of America, p. 57. 

2 Doughty, p. 145. 4 O'Halloran on Yellow Fever, p. 186, et seq. 



488 YELLOW FEVER. 

scription of Louis ; in two the color was a dark olive, and in 
two there was no alteration. Dr. Nott says, further, that he has 
twice met with the straw-colored liver after death from other 
diseases. 1 

Dr. John Harrison, in his Remarks on the Yellow Fever of New 
Orleans, says : " The liver sometimes contains less blood than 
we usually find in the viscus, and, in those cases, it is paler and 
drier than usual. At other times, however, it is engorged with 
blood, and bleeds freely when cut; but these appearances it is 
subject to in common with all the organs, and the existence of one 
or the other appears to depend much upon the condition of the 
patient at the time of the attack, and the treatment he has under- 
gone. In cases where the lancet has been used freely, we shall 
generally find a pale yellow liver"* The interests of science not 
only justify here, as in all similar circumstances, but they demand 
a single criticism. Where results merely are given — and these 
only in general terms — where cases of disease are observed in a 
hospital, by extensive practitioners, constantly and busily occu- 
pied with their private practice, and where these cases are not 
reported in detail, there must inevitably occur, and this not un- 
frequently, errors of diagnosis. That this error was sometimes 
committed in the Charity Hospital, no one can for a moment 
doubt who reads the following statement by Dr. Harrison. He 
says: " In some cases of a low typhoid type, in which there existed 
before death a low nervous delirium, we found, sometimes ulcera- 
tion, and at others hypertrophy and softening of Peyer's glands." 3 
These were unquestionably cases of true typhoid fever ; such at 
any rate is the conclusion which, in the absence of any detailed 
histories of the cases themselves, we are justified in adopting ; and 
if, under such circumstances, cases of typhoid fever could be con- 
founded with those of yellow fever, how much more readily might 
this happen with the more closely allied forms of periodical fever 
— bilious remittent, and congestive. In the Gibraltar epidemic of 
1828, a case was reported to Louis, by Mr. Frazer, as one of 
yellow fever, where the yellow liver was wanting, and in which 
there was ulceration of Peyer's glands. A careful study of the 
case shows manifestly that there had been an error of diagnosis, 

1 Amer. Journ. Med. Sci., April, 1845. 

2 N. 0. Med. and Surg. Journ., vol. ii. p. 138. 3 Ibid., p. 139. 



LESIONS. — GALL-BLADDER. — CONTENTS. 489 

and that the disease was typhoid and not yellow fever. 1 In 
regard to the causes and nature of this peculiar condition of the 
liver, it is quite idle to speculate. We can only call it peculiar, 
or special, and plainly and frankly admit that we know little more 
about it. Clearly enough, it is neither inflammatory nor con- 
gestive, and this is about as far as we can go. It constitutes 
one of the pathological elements — a very common though not a 
constant one — in a specific disease, the result of a specific cause, 
the nature and action of which are yet hidden in absolute dark- 
ness. 

Dr. Richard D. Arnold, of Savannah, has reported a case of 
yellow fever in the American Journal of the Medical Sciences, 
for October, 1842. The liver was pale and ash-colored on its 
entire surface, and throughout its whole structure; and it sil- 
very destitute of blood. Dr. Arnold says : " Dr. Waring, in 1827, 
pointed out to me, in the dead body, as the peculiar characteristics 
of yellow fever, the pale appearance of the liver, its deficiency of 
blood, amounting to a comparative dryness, and the entire absence 
of all biliary secretion. Dr. Barrington, in his account of yellow 
fever on board United States vessels in and near the Gulf of 
Mexico, in 1828, 1829, and 1830, speaks of the liver in two cases 
as of a light color. 2 Dr. Ashbel Smith made seven autopsies at 
Galveston, Texas, in 1839. In three cases, the liver was of a 
very light drab color, externally and internally, and destitute of 
blood ; in one, of a dark claret color, and congested with blood : 
in the others, of its usual appearance, and containing a moderate 
quantity of blood. In all cases, there appeared to be a suspen- 
sion of the biliary secretion ; no bile could be squeezed from the 
substance of the liver. 3 M. Catel says there were one hundred 
and fifty yellow-fever autopsies, at the Hospital of St. Pierre, in 
Martinique, between October, 1838, and September, 1839 ; and 
that the liver was alivays deprived of its color — decolore — and 
yellow ; and the gall-bladder generally empty. 4 

Sec. IV. — G all-bladder, and its contents. Most of the older 
observers, and some few amongst the moderns, describe the con- 
tents of the gall-bladder as nearly or quite natural. Thus, Dr. 

1 Louis on Yellow Fever, p. 124. * Amer. Journ. Med. Sci., Aug. 1833. 
3 Ibid., Feb. 1840. 4 Rapport, &c. Par N. Chervin, p. 12. 



490 YELLOW FEVEK. 

Physick and Dr. Cathrall, in their account of " several dissec- 
tions," made in Philadelphia, in 1793, say that the bile in the 
gall-bladder was quite of its natural color, though very viscid ; 
and Dr. Harrison, in his account of the yellow fever of New Or- 
leans says that the gall-bladder in most cases contains its usual 
quantity of bile, which is to all appearances healthy, although 
sometimes it is greatly inspissated. 1 The weight of evidence is, 
however, quite the other way. Louis says : "It is fair to pre- 
sume on account of the anaemic state of the liver, in individuals 
dying of the yellow fever of Gibraltar, that the secretion of bile 
was not abundant in the course of that disease. Very little of it 
was found in the stomach and small intestines of- the subjects 
whom we have opened; and in the same cases, the gall-bladder 
contained less bile than is found in the victims of other acute dis- 
eases ; and especially less than in those who have died of typhoid 
fever, where the bile is abundant, of a pale color, and of little 
consistence — characters the opposite of those found in the cases 
we are now studying, in all of which, with two apparent excep- 
tions, the bile was thick, scanty, and of a dark green color."* Dr. 
Arnold says: "In all cases that I have ever examined, with the 
exception of viscid bile in the gall-bladder, in vain did I ever look 
for the slightest trace of bile in the dead body. The same is true 
of the excretions during life. Perhaps there may be bile in the 
very beginning of the attack, before a physician is called ; but in 
every case that has ever come under my notice, that has termi- 
nated in black vomit, the absence of bile from the excretions has 
been the distinctive characteristic of the disease." 3 Dr. Nott, of 
Mobile, found the gall-bladder in fifteen of sixteen cases contain- 
ing bile, varying in quantity from half an ounce to four ounces ; 
of a pale-green, olive, or black color ; and its consistence ranging 
from that of water to that of tar. He adds: "The secretion of 
bile in this disease is almost invariably suppressed early ; in severe 
cases, it is rarely vomited after the second day ; and I believe I 
have never seen it after the third day, when they were fatal, ex- 
cept in one or two very protracted cases." 4 Dr. Cooke, in his 
account of the yellow fever of Opelousas, speaks particularly of 
this arrest of the biliary secretion. Of all the phenomena of the 

1 N. 0. Med. and Surg. Journ., vol. ii. p. 138. 

2 Louis on Yellow Fever, p. 140. 3 Amer. Journ. Med. Sci., Oct. 1841. 
< Ibid., April, 1845. 



LESIONS. — SPLEEN, ETC. — GENERAL REMARKS. 491 

disease, he considers this the most constant and characteristic. 
Mr. John McColme, in the letter already quoted, says : " The 
bile in the gall-bladder was of a deeper color, much thicker and 
more viscous than common ; small in quantity, never exceeding 
an ounce ; oftener from half an ounce to six drachms." 1 Dr. 
Robert Jackson says: "The contents of the gall-bladder are 
changed, in almost every case of the concentrated yellow fever, 
into a thick black fluid, resembling tar or molasses." 2 Dr. De- 
veze found the gall-bladder generally empty, but sometimes con- 
taining a small quantity of bile. 3 In a few instances, the gall- 
bladder contains other fluids, or blood. 

Sec. V. — Spleen; mesenteric glands ; urinary organs. No one 
of these organs is the seat of any frequent or important altera- 
tions. Louis and Trousseau found the spleen somewhat softened 
in eight cases; but in half the subjects, it was entirely natural. 

ARTICLE IV. 

MISCELLANEOUS LESIONS. 

Sec. I. — Exterior of the body ; muscles. In most subjects, the 
surface of the body is generally yellow. In three of the cases 
examined by Louis and Trousseau, this color was not present ; and 
when the yellowness was not well marked, it was more so on the 
trunk, and about the head, than on the limbs ; and in some sub- 
jects, it was very slight over the whole extent of the limbs. Ca- 
daverous muscular rigidity is generally strongly marked ; and the 
muscles preserve their healthy firmness, color, and cohesion. 

ARTICLE V. 

GENERAL REMARKS. 

Sec. I. — Relation between Symptoms and Lesions. It is quite 
clear, I think, that the febrile symptoms — the chills, the heat of 
the surface, the accelerated pulse, and so on — cannot with any 
propriety be attributed to local inflammations, in any part of the 

1 Hunter's Dis. of Army, p. 160. 

2 Jackson on Febrile Diseases, vol. i. p. 79. 

3 Traite cle la Fievre Jamie. Par Jean Deveze, p. 66. 



492 YELLOW FEVER. 

body. In the first place, these inflammations, so far as we can 
ascertain from the lesions found after death, are sometimes absent ; 
and, in the second place, we have good reasons for believing that 
the inflammations usually occur after the subsidence, or at least, 
after the partial subsidence of the febrile symptoms. Louis says 
the commencing coldness of the lower extremities usually coin- 
cides with the appearance of the black vomit, and probably de- 
pends upon this gastric hemorrhage. 

There is no evidence of any special connection between the 
state of the tongue and that of the stomach. There can be no 
reasonable doubt, perhaps, that the vomiting in the latter stage, 
and near the close of the disease, is more or less dependent upon 
the lesions of the gastric mucous membrane, which have been 
described; but we shall be carrying our interpretation further than 
our facts will justify us in doing, if we attribute the vomiting, and 
the other gastric and epigastric symptoms, always and invariably, 
to the inflammation of this membrane. The grounds of this qua- 
lification are found in the fact already stated that, in a certain 
proportion of cases, attended like the rest by vomiting, the mu- 
cous membrane of the stomach presents no traces of previous in- 
flammation. If it is alleged here, as it has been, that inflamma- 
tion had existed, but that its results had disappeared with death; 
pur reply is, that the allegation is wholly gratuitous ; and that we 
have no right, in the absence of positive facts, to indulge in asser- 
tions which are necessarily more or less conjectural. In relation 
to the particular question before us, it is, at least in the actual 
condition of our knowledge, more philosophical to refer the vomit- 
ing, as we have referred the production of the matter itself of 
black vomit, partly at least, to some anterior and more specific 
morbid condition, the precise nature of which is yet wholly un- 
known. Similar remarks may be made in regard to the loss 
of appetite, the thirst, the epigastric distress, and the general 
restlessness, so common towards the close of fatal cases. None 
of the symptoms can be referred, with entire constancy or uni- 
formity, to the appreciable lesions of the organs making up the 
pathological anatomy of the disease. 

According to Louis, the colicky pains of the abdomen, which 
are present in a certain number of cases, often coincide in their 
appearance with the discharges of black matter from the bowels ; 



LESIONS. — GENERAL REMARKS. 493 

so that they are probably occasioned by the presence of this 
matter. 

The yellow color and anemic condition of the liver do not reveal 
themselves by any characteristic symptoms during life. It is 
reasonable, however, to attribute the absence of bile from the 
gastro-intestinal discharges to the morbid condition of the liver. 

I am not aware that the suppression of urine, which is occa- 
sionally met with, has been found connected with any apprecia- 
ble alteration of the kidneys. 

The headache which so constantly attends the early period of 
yellow fever, as well as the other local pains, must be regarded 
as purely nervous phenomena, in no way dependent upon any 
appreciable alteration of the cerebral, or the cerebro-spinal, ap- 
paratus; and the same thing is true of the delirium and coma 
which are occasionally present towards the close of the disease. 
These latter symptoms are as common in cases where the brain 
is free from any alteration as they are in cases where the lesions 
are found. For similar reasons, none of these symptoms can be 
referred directly to the inflammation of the stomach, or to any 
other of the local lesions. 

It is very natural that we should refer the yellowness of the 
skin to the morbid condition of the liver, and perhaps this ex- 
planation of the phenomenon is more rational than any other. It 
is quite clear that, in most cases, and it may be in all, there is, 
early in the disease, a suspension of the functions of the liver, 
and it is a very reasonable conclusion that the two phenomena 
are connected. It is well to remember, however, that the yellow- 
ness of the surface is frequently preceded by a more or less in- 
tense sanguineous congestion of the skin, and that the discolora- 
tion may depend upon some modification in the condition of the 
blood, or the action of the cutaneous capillaries, or both, quite in- 
dependent of the state of the liver. The tendency to hemorrhage 
depends also, probably, upon the altered state of the blood. 

The hemorrhagic spots and masses in the tissue of the lungs 
do not indicate their presence by any symptom during life — a 
fact that furnishes us with another lesson, if any such were needed, 
of the danger of trusting, in any degree, to what we call analo- 
gies, or a priori probabilities, however reasonable and plausible 
these may seem to be. 



494 YELLOW FEVER. 

There is no proof that the character of the pulse is dependent 
upon any appreciable morbid alteration of the heart. 

Sec. II. — Causes of Death. The present seems to me as ap- 
propriate a place as any for a few remarks upon the causes of 
death. Keeping myself, as I have always endeavored to do in 
these interpretations, strictly within the authority of well-ascer- 
tained phenomena, what I have to say must necessarily be rather 
approximative and conjectural than positive in its character. 
Considering the rapidity with which the changes in the liver and 
in the mucous membrane of the stomach take place, it is not un- 
reasonable to suppose that; in a certain number of cases, these 
changes, together with the hemorrhagic effusion, play a very im- 
portant part in the destruction of the patient's life ; they may per- 
haps, of themselves, be considered as adequate causes of this 
result. The relative agency and importance of each of these 
phenomena it would be an idle labor to attempt to ascertain. 
There are many cases, however, especially such as are attended 
with but slight lesions or with no appreciable lesions of the 
stomach, in which it seems to me more philosophical to look else- 
where for the causes of death; and in which, if our knowledge 
was sufficiently accurate and extensive, they would probably be 
found in the altered state of the blood, and in other immediate 
and remote effects of the unknown etiological poison of yellow 
fever upon the different tissues of the body. The analogies of 
many other diseases, especially such as are of a malignant or 
congestive character, like Asiatic cholera, scarlatina, typhus 
fever, and so on, are all in favor of this interpretation. 



495 



CHAPTER IV. 

CAUSES. 

In the multitudinous records of the history and literature of 
yellow fever, there is no portion so involved in interminable con- 
fusion and embroilment as that which relates to its causes. After 
as thorough and careful an examination as time and opportunity 
have enabled me to make, I shall now do what I can in endeav- 
oring to render this subject as intelligible as its nature and pre- 
sent condition will admit, following the same general plan by 
which I have been guided in the preceding portions of my book. 

Sec. I. — Locality. Amongst the most striking circumstances 
in connection with the etiology of yellow fever, are those of the 
geographical boundaries within which it is confined, and the more 
circumscribed localities in which it prevails. In the first place, 
the disease is very rarely met with south of the twentieth degree 
of south, or north of the fortieth degree of north latitude. The 
range of latitude, in which it prevails most extensively, lies be- 
tween thirty-six or thirty-seven, and forty-one or forty-two de- 
grees north, in Europe ; and between ten and thirty-five degrees 
north, in America. In the second place, even within these limits, 
yellow-fever is much more frequent in the Western than it is in 
the' Eastern hemisphere, and still further, it is much more common 
in certain portions of Europe and America than it is in Africa. 
In the third place, yellow fever is almost always confined to com- 
mercial seaports ; although it is occasionally met with in the towns 
and cities in the neighborhood of the latter, situated in the inte- 
rior of the country, or on the banks of navigable rivers. In the 
fourth place, yellow fever is very frequently strictly circumscribed 
within certain limited and well-defined portions of the locality, 
or the city, in which it prevails. These four facts in connection 
with this element of the etiology of the disease are well ascer- 



496 YELLOW FEVER. 

tained ; there is no doubt, that I am aware of, or difference of 
opinion in regard to them. 

The places in Europe which have been most frequently and 
most extensively visited by this disease, are the seaports of the 
north coast of the Mediterranean, especially those of Spain. Dr. 
Gillkrest enumerates eighty-five towns or cities in the maritime 
provinces of Andalusia, Murcia, Valencia, and Catalonia, where 
yellow fever has been known to prevail. The most important of 
these are Cadiz, Gibraltar, Malaga, Carthagena, Alicante, and 
Barcelona, all situated on the sea-coast. Dr. Gillkrest says, further, 
that the disease is occasionally met with, to a limited extent, in 
some of the towns and cities at a considerable distance from the 
sea; amongst these, he mentions Cordova, situated on the Gua- 
dalquivir, seventy miles in a direct line from the coast; and 
Konda, sixty miles north of Gibraltar. Similar facts are of fre- 
quent occurrence in the United States. The interior towns which 
are oftenest visited by yellow fever, are those situated above New 
Orleans, on the Mississippi River, especially Natchez and Vicks- 
burg. In 1844, Woodville, a small inland town of Mississippi, 
fifteen miles in a direct line from the river, suffered severely from 
the disease ; as did also many isolated plantations in the surround- 
ing country. 1 

The principal seats of the disease, in America, are the towns 
and cities lying along the shores of the Atlantic Ocean, from 
Charleston, south ; along those of the entire Gulf of Mexico, and 
of most of the West India Islands. The shores of this western 
Archipelago and Gulf, constitute the great and prolific hot-bed in 
which is constantly generated the unknown poison of the dis- 
ease; they have been the crowded Necropolis of the successive 
swarms of adventurers and invaders, who have annually flocked 
thither from Europe and America, ever since their discovery. 
Chisholm says, in his dedication, that more than twelve thousand 
of his countrymen have perished within these islands in the short 
space of two years ! 

In connection with the localities, or the habitat, of yellow fever, 
it is important to notice that it frequently occurs and prevails 
extensively on shipboard. This has been so often witnessed as 
to render it quite certain that, in yellow-fever seasons, and places, 

1 N. 0. Med. Journ., vol. i. p. 530. 



CAUSES. — LOCALITY. 497 

the hold of a ship often constitutes a very prolific nidus for the 
generation of the poison of the disease. Dr. Gillkrest enumerates 
nearly forty vessels or squadrons, in which at different periods 
the disease has appeared. 1 The first appearance of yellow fever 
on shipboard usually takes place while vessels are in port, or very 
soon after they have left port. Dr. Burnett, who saw a great deal 
of the disease in the ships of the British fleet on the Mediterranean 
station, says that, with one exception, he never knew an instance 
where the crew of a vessel were attacked after being some time at 
sea. 2 Dr. Currie, of Philadelphia, supposed that crowded trans- 
ports, or ships of war, generally, if not always, constituted the 
original and proper sources of the matter of contagion, or the poi- 
son of the disease. 3 Dr. Barrington says that the disease made 
its appearance on board the United States ship Hornet, in 1828, 
while lying at Sacrificios, a small island about three miles from 
Vera Cruz. The ship had been lying there at anchor twenty-six 
days, when the first decided case occurred ; there was no epide- 
mic in the city of Vera Cruz, excepting the dengue ; nor was the 
fever prevalent at any place where the vessel had touched during 
her cruise. There can hardly be a doubt as to the origin of the 
disease, here, in the ship. Other cases of a like character are on 
record. In 1799, the frigate General Green sailed from Newport, 
Rhode Island, for Havana. She had tempestuous weather, 
leaked badly, and became very foul, the weather being excessive- 
ly hot. Yellow fever appeared amongst her crew before she ar- 
rived in port, which was at the time free from the disease. 4 M. 
Chervin has collected a considerable number of similar instances, 
which seem to be well authenticated, and which, so far as I know, 
are uncontradicted. 5 

There is another circumstance in connection with the preva- 
lence of yellow fever on shipboard, which ought to be stated. 
The disease is said in many instances to be confined to certain 
portions of the ship ; or at least to prevail more extensively in cer- 
tain portions than in others. Dr. Wilson says: " It is always at 
the beginning confined to a small space. It often continues for 
awhile in one berth, whence it sometimes crosses to the opposite 
berth ; sometimes it travels along one side, returning pretty regu- 

1 Cyc. Prac. Med., vol. ii. p. 270. 3 Burnett on the Med. Fever, p. 3. 

3 Carrie's Dis. of Am., p. 60. 4 Deveze, p. 158. 

5 Rapport de l'Acad. Roy. de Med., 1827, p. 9. 

32 



498 YELLOW FEVER. 

larly by the other ; and sometimes it traverses the ship from the 
rear to the forepart, or in a contrary direction. But in a majority 
of instances, it begins in the vicinity of the pumps and main ' 
hatchway, where the shell of the ship is most dependent, where 
water draining from other parts collects, and where heat is most 
intense." 1 

The fact of the limitation of yellow fever to certain well-defined 
quarters, or neighborhoods, of the cities in which it is epidemic 
has been so generally observed, that it is hardly neeessary to mul- 
tiply examples of this limitation. The extension of the boundaries 
of this infected district, as it is called, almost always takes place 
gradually. Dr. Nott, of Mobile, in a private letter to me, says : 
" I have, on two occasions, seen yellow fever commence in a point 
in the town, and eat through it, square by square, like worms in 
a cotton field — taking each time nearly a month for this process." 
Arejula, in his account of the epidemic of Cadiz, in 1800, says : 
" We also ascertained that the disorder not only spread from one 
individual to another, but that it passed from one house to the next 
adjoining, and so on along the street, ultimately affecting the 
whole district. 2 Arejula also gives an account of the origin and 
spreading of the disease at Malaga, in 1803. He traced it regu- 
larly and gradually from its focus, first to one house, then to an- 
other adjoining, and so on through a whole street or district. 3 M. 
Berthe, who was one of the French commission to investigate the 
epidemic of Andalusia, in 1800, says : " It was distinctly ob- 
served that the malady affected to seize, with scarcely any inter- 
ruption, all the houses which were situated on the same side of a 
street, and that it rarely passed over to the other side, where the 
streets were wide and well aired. In some parts of the town the 
distemper has been seen to stop, as it were, for a time, as soon as 
it had reached to houses standing in a public square, and even to 
retrograde with respect to the direction in which it had previously 
advanced, by appearing in the adjoining houses, rather than in 
those which were separated by the breadth of the square." 4 The 
Cadiz epidemic of 1800 commenced in a quarter of the city called 
the Barrio de Santa Maria, to which quarter it was at first con- 
fined ; it gradually spread to other portions of the city. The same 

1 Memoirs of West Indian Fever, p. 157. 3 Ibid., p. 164. 

2 Reports, etc., by Sir J. Fellowes, p. 36. 4 Bancroft's Essay, p. 459. 



CAUSES. — SEASON. 499 

thing is true of other epidemics. Dr. Hosack says: "Whenever 
the yellow fever has been introduced into the cities of the United 
States, its first extension has always been slow and gradual. 
Upon several occasions its boundaries have been accurately de- 
fined by our board of health. This was remarkably the case in 
New York, in 1805. The disease in that year was confined for 
some weeks to a small portion of the eastern side of the city, and, 
as stated by the board of health, not a case occurred in any part 
of the town that was not referable to that as its source. In a 
short time, the infection extended a few streets further ; the board 
of health again defined its limits, and again declared that still 
not a case had occurred that could not be traced to this part of 
the city as its source." 1 The disease at Gibraltar is almost al- 
ways confined to the western face of the rock, and to a small vil- 
lage situated at the base of the rock, on its eastern side. 

Sec. II. — Season. The period of the year during which yel- 
low fever prevails most extensively, varies with the climate and 
temperature of different localities. In the cities of the United 
States, it usually commences in the months of July or August, 
and continues till the first frost. The great epidemic of 1793, 
in Philadelphia, began early in August, and ceased about the 
middle of October; the largest daily mortality taking place 
during the second week of the latter month. At Seville, in 1800, 
the epidemic commenced on the 23d of August, and continued till 
December ; the principal mortality was in October. 2 

The editors of the Neio Orleans Medical Journal have pub- 
lished a tabular statement of the cases of yellow fever received 
into the Charity Hospital of that city, for twenty-one successive 
years, from 1822 to 1843, inclusive, with the dates of the first 
and last case for each year. During fifteen of these twenty-one 
years, the disease was sufficiently extensive to be called epidemic ; 
the number of cases received ranging from ninety-four to eleven 
hundred and thirteen. The dates of the first receptions vary 
from May 23 to September 3, the largest number falling in the 
months of July and August. The dates of. the last receptions 
vary from November 13 to December 31; the largest number 

1 Hosack's Med. Essays, vol. i. p. 309. 

2 Reports, etc., by Sir J. Fellowes, p. 421. 



500 YELLOW FEVER. 

falling in the month of November, and almost always after its 
middle period. 1 Sir James Fellowes has published a similar 
abstract in connection with the general Spanish epidemic of 1804. 
He gives the population of twenty-three towns in which the 
fever prevailed ; the period of its commencement and cessation 
in each, the day of the largest mortality, the total number of 
deaths, and the proportion of males and females. The earliest 
period of the commencement of the disease was June 29, at 
Malaga ; the latest period was October 5, at Villamartin, a small 
town in the province of Seville ; the disease began in ten towns 
in August, in nine in September, and in three in October. 
The earliest period of the cessation of the disease was October 28, 
at Grenada ; the latest period was January 23, at Carthagena. 
The disease ceased in the course of October in one town, in 
November in seven, in December in twelve, and in January in 
two. 2 Mr. Doughty says that, in Jamaica, the disease generally 
prevails from the beginning of August to the end of December 
or January. 

Sec. III. — Temperature, and Weather. That yellow fever is a 
disease of warm climates, and that it prevails most extensively 
during the warmest seasons of the year, no one pretends to deny 
or to doubt. But some observers have gone further than this, 
and have alleged that the disease is much more likely to occur, 
in the localities that are subject to it, in very warm and wet 
seasons, than those that are somewhat cooler and drier. They, 
assert that there is a general connection between certain appre- 
ciable states of the weather and the disease. Dr. Hosack says 
yellow fever prevails most extensively when the air is unusually 
moist and the weather hot. 3 Dr. Doughty says it is more likely 
to occur in the West Indies, after copious rains. Sir Gilbert 
Blane said that the fever was restricted to those regions where 
the range of the temperature was as high as 80°. Others have 
alleged that the disease can occur only in those places where the 
average temperature at 3 o'clock P. M. is not less than 79°, 
during the summer, and especially during the two whole months 
of June and July ; and that its extent and severity will be in 
proportion to the degree in which it exceeds this point. There is 

1 N. 0. Med. Journ., vol. i. p. 103. 

2 Reports, etc., by Sir J. Fellowes, p. 478. 

3 Hosack'-s Med. Essays, vol. i. p. 305. 



CAUSES. — TEMPERATURE. — WEATHER. 501 

no doubt, whatever, that the disease is generally found where 
these high temperatures prevail ; but it is far from being settled 
that the disease is directly and immediately dependent upon these 
degrees of heat ; yellow fever has sometimes occurred at Stoney 
Hill, in Jamaica, thirteen hundred feet above the level of the 
sea, with a mean annual temperature of only 70°. 

Sir James Fellowes gives tables of the temperature, furnished 
by Arejula, at Cadiz, from 1789 to 1803; from which it is quite 
clear that the hottest years were not the sickliest. They show no 
apparent connection between the temperature and the disease. 1 
Hillary, who studied this subject with great care, says : " It does 
not appear, from the most accurate observations of the variations 
of the weather, or any difference of the seasons which I have 
been able to make for several years past, that this fever is any 
way caused or much influenced by them, for I have seen it at 
all times, and in all seasons of the year, in the coolest as well as 
in the hottest time of the year; except that I have always ob- 
served that the symptoms are generally more acute, and the 
fever usually higher, in a very hot season, especially if it was 
preceded by warm, moist weather, than it usually is when it is 
more cool." 2 M. Catel believes that the epidemic prevalence of 
yellow fever at Martinique and at other places is greatly favored 
by the warm and humid winds from the southeast; and by a 
stagnant atmosphere. 3 He says, further, that at Martinique the 
disease is always rendered more severe and malignant, by violent 
thunder-storms. Dr. Gillkrest, in his account of the Gibraltar 
epidemic of 1828, says: "By ample tables in our possession, it 
does not appear that, either before the appearance of the disease 
in the garrison, or during its progress, any atmospheric changes 
took place, differing materially from other years in which epi- 
demics did not occur. The average heat was not greater than 
that of the preceding yera\ The quantity of rain, which had 
fallen up to the appearance of the epidemic, was within a fraction 
of that which fell in 1827. The influence of a prevalent easterly 
wind had been much dwelt upon in the explanations offered re- 
specting the epidemic of 1804 ; but, in 1828, no unusual preva- 
lence of that wind took place." 4 According to Humboldt, there 

1 Reports, etc., by Sir J. Fellowes, p. 413, et seq. 

2 Rush's Hillary, p. 107. 3 De la Fierce Jaune, &c, par M. Catel. 
* Cyc. Pract. Med., vol. ii. p. 279. 



502 YELLOW FEVER. 

was no yellow fever at Vera Cruz for eight years previous to 1794, 
although there was nothing unusual in the state of the weather 
during this period. 1 The editors of the New Orleans Medical 
Journal, in their notice of the health of the city for 1844,. make 
the following remarks: " The health of New Orleans was per- 
haps never known to be better. No epidemic whatever has pre- 
vailed during the year. The summer has been one of the hottest 
ever experienced, with frequent showers during July and August. 
Thus it would appear we have had a large share of two of what 
have generally been considered the most essential agents in the 
production of the remote cause of summer and autumnal diseases, 
to wit, heat and moisture. As to the other ingredients, dead 
animal and vegetable matter, one would suppose there was never 
any deficiency, about such a place as New Orleans. Well, we 
have here all the hypothetical elements of hypothetical malaria; — 
but where are the much dreaded consequences?" 2 The Board of 
Health of the city of New Orleans, in a report made in 1846, 
say : " The experience of former years would lead us to conclude 
that more or less rain, or a greater or less degree of heat, has very 
little to do with the production of yellow fever ; for that disease 
has been known to prevail here alike in dry and wet seasons, and 
without regard to the variations of temperature in the summer 
months." 3 

Sec. IV. — Age. Writers upon yellow fever very rarely say 
anything about the age of its subjects. The reasons are suffi- 
ciently obvious why a very large proportion of its victims Siould 
be those in the middle and most active period of life. It occurs, 
however, not unfrequently amongst children. 

Sec. V. — Sex. It is quite certain that yellow fever destroys 
very many more males than females ; b # ut in order to determine 
positively the real difference in the susceptibility of the sexes to 
the disease, more accurate and conclusive investigations are 
necessary than have yet been made. The great and uniform 
preponderance of male over female deaths is in no degree suffi- 
cient to settle this question ; since it is obvious, at first sight, 
that, under the circumstances which generally attend the epidemic 

1 Cyc. Pract. Med., vol. ii. p. 291. 2 ^. 0. Med. Journ., vol* i. p. 216. 

3 Ibid., vol. ii. p. 475. 



CAUSES. — SEX. 503 

prevalence of yellow fever, the number of males who are exposed 
to the essential cause of the disease, and who are at the same time 
susceptible of the disease, is almost always vastly greater than 
that of females. The mortality from yellow fever is almost 
wholly confined to strangers, and the unacclimated in cities 
where it prevails, and a vast proportion of these are men. I do 
not mean by these remarks to deny that females are less liable 
to the disease than males: I mean merely to say that the apparent 
results of the tables of mortality do not justify the conclusions 
ivhich have been drawn from them, for the obvious reasons that 
I have just given. In this connection, it would be interesting 
and important to ascertain whether there is any difference, 
depending upon sex, in the liability of the children of residents 
in yellow fever cities to the disease. After these qualifying 
remarks, the reasonableness and necessity of which can hardly 
be called in question, I proceed to state some of the results of 
observation, in regard to the actual difference in the prevalence 
of the disease in the two sexes. In a short but interesting 
paper on the History, Topography, and Causes of Yellow Fever, 
by Dr. Bennet Dowler, published in the second volume of the New 
Orleans Medical Journal, notice is taken of a terrible epidemic 
which ravaged the Island of Barbadoes in 1647. In a history 
of the epidemic, published by Ligon, ten years after its occur- 
rence, it is stated, that " for one ivoman that died, there were 
ten men." Dr. Gillkrest says : " In some epidemics, females 
have remained wonderfully exempt ; this was the case during a 
terrific epidemic at Dominique and Martinique, in 1801, as the 
writer of this witnessed; for while two battalions of the 68th 
regiment, composed of fine young men, suffered so much from 
the disease as not to be able latterly to furnish any men for duty, 
and had lost forty-six officers within six months, not a single 
woman was attacked ; and it may be observed that, in those days, 
more females were allowed to embark with regiments from home 
than at present." 1 

During the Spanish epidemic of 1804, the aggregate mortality 
in twenty-three towns was 45,822; the male deaths amounting to 
28,352, the females to 17,470. This general result, on so large 
a scale, would seem quite conclusive as to the greater liability of 

1 Cyc. Prac. Med., vol. ii. p. 279. 



504 YELLOW FEVER. 

the male than the female sex to this disease ; but a closer exami- 
nation and analysis of the table will strengthen the doubts that I 
have already ventured to express, in relation to this subject. 
Taking five of the large seaports, the difference in the mortality 
of the sexes is very great, as might naturally be supposed. The 
male deaths in Malaga, Alicante, Cadiz, Carthagena, and Velez 
Malaga amount to 21,805, and the females to only 11,713. But 
in five of the larger inland towns, more or less removed from 
the coast, where we have a right to presume there are fewer 
strangers and sailors, the female mortality exceeds even that of 
the male, the former amounting to 8961, and the latter to 
3576. In Ecija, an interior town of Seville, some eighty miles 
from the sea, the male mortality was 1380, and? the female 
2422. * The aggregate mortality in Charleston, S. C, dur- 
ing ten years, between 1817 and 1839, was as follows : Males, 
nine hundred and seventy-six ; females, one hundred and seventy- 
eight. 

Sec. VI. — Race. The African race is less liable to yellow 
fever than the Caucasian. The comparative exemption of ne- 
groes from the disease has long been noticed. During the Phila- 
delphia epidemic of 1793, Dr. Rush published in one of the daily 
newspapers the following extract from Dr. Lining's History of the 
Yellow Fever, as it had four times appeared in Charleston, South 
Carolina : " There is something very singular in the constitution 
of the negroes, which renders them not liable to this fever; for 
though many of them were as much exposed as the nurses to the 
infection, yet I never knew of one instance of this fever amongst 
them, though they are equally subject with the white people to 
the bilious fever." In consequence of this publication, the Afri- 
can Society voluntarily offered to furnish nurses and attendants 
for the sick. " It was not long," continues Dr. Rush, " after 
these worthy Africans undertook the execution of their humane 
offer of services to the sick, before I was convinced I had been 
mistaken. They took the disease in common with the white peo- 
ple, and many of them died with it. A large number of them 
were my patients. The disease was lighter in them than in white 
people. I met with no case of hemorrhage in a black patient." 2 

1 Reports, etc., by Sir J. Fellowes, p. 478. 

2 Rush's Med. Inq., vol. iii. p. 80. 



CAUSES. — CONSTITUTION. 505 

Dr. Lewis, in his account of the Mobile epidemic of 1843, says : 
"Negroes were frequent subjects of fever; these cases were simi- 
lar to the mild grade of the yellow fever of the season, yet never, 
as far as my observation extended, arriving at the stage of black 
vomit; nor did a single case prove fatal in my practice amongst 
this class of persons. Some four or five mulattoes died of black 
vomit, during the season. Many cases terminated in the charac- 
teristic hemorrhages, and others again passed through all the 
stages of grave yellow fever, requiring the same active stimula- 
tion to sustain them in the collapse stage that were used under 
similar circumstances with the whites. These cases were con- 
fined to the mulattoes. Notwithstanding the great fatality that 
attended this class in 1813, we are bound to conclude that, as a 
general rule, they are exempt from the noxious influence of the 
poison of yellow fever. They constitute, especially in autumn, a 
large portion of our population ; many of them recently from Vir- 
ginia, and the Carolinas, coming strictly under the head of unac- 
climated persons. Those unacclimated suffer more than those 
long resident amongst us; still, they have black vomit so seldom 
as scarcely to constitute an exception to the general rule.'" 1 In 
1820, says Dr. Daniell, near three hundred native Africans, 
recently captured on the coast, by government vessels, were 
brought into Savannah. They remained there during an epidemic 
yellow fever, but not one suffered from the disease. 2 Dr. Dick- 
son says he has never known an African negro to be attacked by 
yellow fever. 3 

Sec. VII. — Constitution. It would seem that yellow fever is 
more likely to attack the stout and plethoric than the more feeble 
and delicate. Mosely says the disease is incidental only to the 
gross, inflammatory, and plethoric ; and again: "Subjects most 
likely to be attacked by the Endemial Causus, are the florid, the 
gross, the plethoric— that sort of strong, full, youthful people, 
with tense fibres, who in England are said to resemble the pic- 
ture of health." Sir Gilbert Blane says : " Those who are young, 
fat, and plethoric, are most apt to be attacked ; and more of our 
officers in proportion were seized with it than the common men." 4 
It should be remembered that a pretty large proportion of the un- 

1 N. 0. Med. Journ., vol. i. p. 416. 2 Fevers of Savannah, p. 64. 

"Dickson's Essays, &c, vol. i. p. 345. 4 Obs. Dis. Seamen, p. 398. 



506 YELLOW FEVER. 

acclimated are likely to consist of this class of persons — the 
young, active, and robust, coming from cooler climates. 

Sec. VIII. — Occupation. The largest number of persons de- 
stroyed by yellow fever are soldiers and sailors, the reasons for 
which are sufficiently obvious. It is alleged, by many writers, 
that there are certain occupations which render persons engaged 
in them to a great extent exempt from the disease. This has been 
said to be the case with butchers, and workers in leather, soap, 
and tallow. I do not think there is any good reason for this 
opinion — the evidence upon which it is founded, so far as I can 
judge, being altogether inadequate. Dr. Gillkrest says: "Cir- 
cumstances connected with localities being equal, the upper 
classes of society seem, on all occasions, to suffer from attacks 
in a full proportion." 

Matthew Carey, in his account of the Philadelphia epidemic of 
1793, says: " To the filles de joie, it has been very fatal. The 
wretched debilitated state of their constitutions rendered them an 
easy prey to this dreadful disorder, which very soon terminated 
their miserable career. To hired servant-maids it has been very 
destructive. Numbers of them fled away ; of those who remained, 
very many fell, who had behaved with an extraordinary degree of 
fidelity." 1 In this connection it may be added, that all the attend- 
ants upon the General Hospital of Barcelona, during the epidemic 
of 1821, who died with yellow fever, are said to have been suf- 
fering at the time under chronic diseases. Dr. O'Halloran says 
the physicians of Barcelona generally remark that scarcely an 
individual escapes an attack of yellow fever who labors under 
venereal or chronic disease. 2 

Sec. IX — Acclimation. In this chapter, more appropriately 
than anywhere else, maybe placed a few remarks upon the influence 
of a prolonged residence in yellow-fever localities, in rendering the 
system unsusceptible to the poison of the disease. This change 
in the system is called acclimation. It is most speedily and 
effectually wrought by the occurrence of the disease itself; but it is 
quite evident that it may be more slowly and gradually effected 
by a continued residence in yellow fever regions. The precise 

1 Carey's Short Account, etc., p. 61. 2 O'Halloran on Yellow Fever, p. 98. 



CAUSES. — ACCLIMATION. 507 

conditions and causes of this exemption have not been very posi- 
tively ascertained, and it is probable that they vary somewhat in 
different cases. There is a great difference, in different seasons 
and places, in the degree of protection afforded by this modifica- 
tion of the system. During mild epidemics, the protection is 
quite perfect ; but when the character of the disease is highly 
malignant, the protection in many instances wholly fails. Some 
observations relating to this subject, by Dr. Lewis, will be found 
in the chapter on bibliography. He says, further, that " Of one 
hundred and twenty cases that terminated fatally at Mobile, in 
1843, seven were natives, three were from Charleston, five from 
New Orleans ; twenty had resided in Mobile from five to ten 
years, annually avoiding the sickly months ; fifteen had been con- 
stantly in the city from four to seven years — amongst whom 
were four who had the fever in 1839. Sixty were strangers, never 
having passed a summer in a yellow-fever locality. These facts 
tend to the following conclusions. In healthy years, what is called 
sporadic yellow fever is confined to strangers. In years when the 
disease does not prevail so generally as to amount to an epidemic, 
the grave cases are confined to the unacclimated. In epidemics, 
the natives, old residents, and even those who have had the disease 
in previous years, are frequently mildly attacked ; but the strangers 
are very generally seized, and have, in fact, to bear the violence 
and malignity which belong to the fever." 1 

It would seem that this protective power of acclimation does 
not extend to localities which are usually exempt from the dis- 
ease. A very remarkable circumstance in support of this remark 
occurred at Woodville, in Mississippi, in 1844. This inland town 
then contained about eight hundred inhabitants, mostly natives, 
or old and permanent residents. At least it is stated that the 
town had been of gradual growth, for forty years, and that there 
had been no sudden emigration. After the appearance of yel- 
low fever in the town, nearly two hundred persons fled to the 
surrounding country; but nearly all who remained were attacked 
by the disease. Dr. Stone, in his report, says: "Few persons 
escaped; I know of not more than five adults, and no children, 
except those persons, about twenty in number, who had had yel- 
low fever formerly. Of these, one had it in Charleston, forty 

1 N, 0. Med. Jourii., vol. i. p. 418. 



508 YELLOW FEVER. 

years ago; others in New Orleans, Bayou Sara, Natchez, the 
West Indies, and elsewhere; and all escaped, with perhaps one 
exception — a mild case." 1 

The great endemic of the western coast of Africa is periodical 
fever; but yellow fever has occasionally appeared at some of 
the settlements. It prevailed at Sierra Leone, in 1823, and in 
1829, and was as fatal amongst the old residents as the new- 
comers. 2 

It would seem that at certain times, and in certain localities, 
the poison of yellow fever acquires such an intensity as to over- 
bear all the influences which ordinarily resist it. Everything 
gives way before it; neither age, sex, nor race is spared; and 
not even the most thorough acclimation, nor the previous occur- 
rence of the disease, is sufficient to ward off its assaults. 

This preservative influence of acclimation seems to be pretty 
readily lost or destroyed, or. at least greatly diminished, by a re- 
moval from yellow-fever regions to cooler latitudes. Bally re- 
ports the case of a lady, who, born in Canada, had resided for 
thirty years in one of the Antilles. After an absence of two 
years, passed in the North, she returned, and soon after died with 
yellow fever, at the age of fifty-four years. 3 

Sec. X. — Exemption from Subsequent Attacks. Yellow fever 
very rarely occurs a second time in the same individual. This 
exemption from a second attack of the disease was noticed 
during the last century; and it has been since corroborated by 
the observations of many French, English, Spanish, and Ameri- 
can physicians, amongst the earliest and most distinguished of 
whom were Professor Arejula, and Sir William Pym. This point 
in the natural history of yellow fever was made the subject of a 
special and formal investigation, after the cessation of the epi- 
demic at Gibraltar, in 1828. At the instance of Sir William 
Pym, a commission was appointed, for the express purpose of 
collecting such facts as might settle the question. The commis- 
sion consisted of thirteen physicians— French, English, and 
Spanish. Louis was appointed President, Dr. Barry, Vice-Pre- 
sident, and Trousseau, Secretary. The distinguished Chervin 

1 N. 0. Med. Journ., vol. i. p. 532. 2 Boyle's Dis. West. Africa, p. 289. 
3 Deveze, p. 107. 



CAUSES. — SECOND ATTACK. 509 

was also a member of the commission. The medical men of 
Gibraltar, civil and military, thirty-three in number, all of whom 
had been familiar with the disease, appeared before the commis- 
sion, and stated the results of their experience. The aggregate 
number of patients with the disease, seen or treated by them all, 
amounted to about twenty-seven thousand. These physicians 
were invited to state the number of cases in which they had 
known the disease to occur a second time ; and as simple asser- 
tions were inadmissible, the commission decided that they would 
receive those cases only in which the symptoms of the first and 
second attacks could be given, whether these symptoms had been 
noted by the physicians who communicated them, or whether they 
came through the patient himself, but were unequivocal. The 
whole number of cases of presumed double attack, thus commu- 
nicated to the commission, was only thirteen ! Upon these thir- 
teen cases, each member of the commission expressed his opinion 
by a vote, writing upon a piece of paper the word evident, pro- 
bable, doubtful, or inadmissible, for each case. A majority of the 
commission declared in this manner one of the cases evident, 
three of them probable, and the remainder doubtful or inadmis- 
sible. The following fact on a much smaller scale, but hardly 
less conclusive, was communicated to the commission by M. 
Broadfoot. The military domestics employed during the epi- 
demic in the care of the sick were one hundred and sixty in 
number, and none of them had had yellow fever in any anterior 
epidemic. The civil domestics were sixty-one in number, and 
with two exceptions had already had the disease. These two, 
and these two only, amongst the last, had the disease ; and forty 
of the military domestics, all the rest escaping. Other facts of a 
similar character were also presented to the commission. Slight 
and mild attacks of the disease seemed to be quite as preserva- 
tive against its recurrence as grave and severe ones ; and it did 
not appear that the protective effects were in any degree dimi- 
nished by time. 

Dr. Lewis has investigated this question with some care, and 
the result of his inquiries differs somewhat from that which I have 
just given. Five respectable citizens of Mobile, he says, have 
had the disease as many as three times, according to the testimo- 
ny of competent judges. As many as twenty of his own patients, 
who were mildly attacked in 1843, stated that, according to their 



510 YELLOW FEVER. 

physicians, they had already had yellow fever during the epide- 
mics of 1837 or 1839. Dr. Lewis concludes that, in 1843, 
about one-fifth of the patients who had mild yellow fever, had 
been subjects of the disease during previous epidemics. His 
opinion seems to be that, at least during the prevalence of grave 
epidemics, persons who have previously had the disease are, to a 
liable to second attacks in a mild form. 1 

Sec. XI. — Epidemic Influences. Yellow fever usually prevails 
in a given locality more or less extensively ; it becomes for the 
time being, as it is said, epidemic. The returns or recurrences 
of these epidemic seasons are altogether uncertain -and irregular; 
— they give no note of their coming ; the laws which govern the 
revolutions of their periods are wholly unknown to us. One of 
the most remarkable and extensive of these large epidemic periods, 
was that which commenced in the year 1793, and continued for 
several years. I do not propose to go into any extensive or ge- 
neral enumeration of the epidemics whose histories have been 
preserved. 

It has been said that the visitations of the disease, in New 
Orleans, had shown a tendency to observe alternate years; but 
an examination of the facts, as they have been published, during 
a continuous period of twenty-two years, from 1822 to 1843, 
both included, gives but little support to this suggestion. From 
1833 to 1841, the epidemic prevalence of the disease returned, 
with a good deal of regularity, on each alternate year ; but from 
1827 to 1830, and from 1841 to 1843, the disease prevailed re- 
gularly every year. According to Dr. Simons, the first appear- 
ance of yellow fever in Charleston, was in 1690 or 1700. It has 
since occurred in the following years, to wit : 1703, 1728, 1732, 
1739, 1745, 1748, 1753, 1755, 1792, 1794, 1795, 1796, 1797, 
1798, 1799, 1800, 1802, 1804, 1807, 1817, 1819, 1824, 1827, 
1828, 1830, 1834, 1835, 1838, and 1839. 2 Dr. Catel says that 
Martinique was almost entirely exempt from the disease, except 
a few sporadic cases, from 1828 to 1838. 3 

" That the essential cause of yellow fever," says Dr. Dowler, 
"will ever be discovered, or, being discovered, will be controlled 

1 N. O. Med. and Surg. Journ., vol. i. p. 418. 

2 Am. Journ. Med. Sci., Feb., 1836. 3 Rapport, &c, par M. Chervin, p. 6. 



CAUSES. — SPORADIC. 511 

or prevented by human art, is altogether improbable. Its myste- 
rious cycles culminate, decline, and reappear. Charleston, deso- 
lated at the close of the seventeenth century, was exempt in the 
first quarter, but a sufferer in the second quarter of the eighteenth, 
and then, half a century of exemption again followed — a period 
much longer than that which now cheers the cities of New York, 
Philadelphia, Boston, and Baltimore, with the hope that yellow 
fever has taken its leave of them forever. But the last decennial 
period of the past century, and the first of the present, relumed 
the flames of the epidemic in Charleston, where they had smoul- 
dered so long, and in which they still continue to break out almost 
annually. Charleston suffered nearly a century in advance of 
New Orleans, and is still as great a sufferer as the latter. " J There 
is nothing in the past history of the disease at all incompatible 
with the probability that the elliptical sweep of its epidemic pe- 
riods may again bring it within the more northern cities, from 
which, for many years, it has been absent. 

Sec. XII. — S})oradic. Yellow fever, as I have just said, gene- 
rally prevails in the form of an epidemic ; but this is not always 
the case. It is now very well ascertained that yellow-fever cities 
are sometimes visited by isolated, sporadic cases of the disease. 
The question of the occurrence of the disease in this form was 
carefully studied by Louis and Trousseau at Gibraltar, in 1828. 
Mr. Amiel and Mr. Fraser communicated to them the histories 
of forty-five cases, derived from the hospital registers, which had 
occurred during non- epidemic seasons. Some of these cases, Louis 
regards as spurious or doubtful ; but he is quite confident of the 
genuineness of the others. Dr. Gillkrest says he is in possession 
of such a body of evidence, drawn from registers and other 
authentic sources at Gibraltar, as would, of itself, place the mat- 
ter beyond all doubt. He adds that in the month of April, 1829, 
the records of the civil hospital in that garrison were examined, 
and a certificate drawn up and signed by nine gentlemen, to the 
effect that thirty-eight cases, of which they found details duly re- 
corded in non-epidemic years, were identical in character with the 
cases which occurred there during the epidemic of 1828. 2 Mr. 
Glasse, who was for a long time a resident at Gibraltar, says, in 

1 N. 0. Med. Journ., vol. ii. p. 173. 2 Cyc. Prac. Med., vol. ii. p. 270. 



512 YELLOW FEVER. 

a letter to Dr. Burnett : " During the spring and autumn, I have 
been in the habit of seeing solitary cases of fever attended with 
black vomiting, and other severe symptoms." 1 

Sec. XIII. — Marsh Miasmata. Medical men who look upon 
yellow fever as only a high grade, or concentrated and malignant 
form, of bilious remittent fever, attribute the disease to the un- 
known cause or causes of the latter, called marsh miasmata, 
developed in unusual quantity, or endowed with extraordinary 
virulence. This is the opinion advocated by Dr. Bancroft, in 
his elaborate treatise on the causes of this and other epidemic 
diseases; and by many others, who believe in the local and do- 
mestic origin of the disease. 

But the objections to this opinion are obvious and insuperable. 
In the first place, it is as well settled as any such question can 
be, that yellow fever differs, radically and essentially, from all the 
forms of periodic or marsh fever. The two diseases may prevail 
together — as marsh fevers and smallpox, or typhus, may — but 
this is rarely the case; and in very extensive regions, where pe- 
riodical fevers in their worst forms constitute the principal dis- 
eases, yellow fever is never seen. Again, in many yellow-fever 
localities, there is no evidence, whatever, of the existence of 
marshes, or marsh miasma. Dr. Gillkrest says : "It cannot be 
admitted that Gibraltar furnishes sources from which malaria, in 
the usual sense of that word, arises, sufficient to account for the 
appearance of a malignant fever." 2 In 1844, yellow fever pre- 
vailed very extensively at Woodville, a small town in the interior 
of Mississippi. The town is built on a rolling ridge, three hun- 
dred and forty feet above the bank of the Mississippi River; the 
soil is clay and sand; the town is free from filth; and there .are 
no swamps or ponds in the neighborhood. 3 The Island of Barba- 
does is described as rocky and dry, with very little marshy or wet 
land. 4 Brimstone Hill, in the Island of St. Kitts, is a conical 
mount, rising to the height of seven hundred feet above the level 
of the surrounding plain. It is described as a volcanic rock, dry, 
nearly destitute of vegetation, and desolate in its entire aspect. 
It is generally free from yellow fever, but not uniformly so. In 

1 Burnett, p. 329. 2 Cyc. Prac. Med., vol. ii. p. 279. 

3 N. 0. Med. Journ., vol. i. p. 530. « Rush's Hillary, p. 5. 



CAUSES. — ANIMAL AND VEGETABLE DECOMPOSITION, ETC. 513 



1811 and 1812, the disease appeared there, and was very fatal. 
Stoney Hill, in Jamaica, is thirteen hundred feet above the level 
of the sea. It is described as an entire mass of calcareous rock, 
covered with trees, excepting on the summit; but with little soil, 
and producing scarcely any grass or herbaceous plants. It is 
generally healthy; but yellow fever does sometimes prevail, exten- 
sively and fatally, amongst the troops stationed on its summit. 
Furthermore, the frequent occurrence of the disease in ships at 
sea is entirely incompatible with the doctrine of which I am now 
speaking ; and the whole subject may be fairly and definitively 
dismissed with an expression of surprise that the doctrine could 
ever have found any countenance or favor. 

Sec. XIV. — Decaying Animal and Vegetable Matter. — Filth. 
In the almost interminable discussion which has been going on 
during the last half century about the causes of yellow fever, 
there is no one element that has played a more prominent part 
than the decay or decomposition of animal and vegetable matter. 
Most of the advocates of what is called the domestic origin of the 
disease, and the deniers, at the same time, of its contagious pro- 
perties, have attributed it principally to this animal and vege- 
table decomposition, and to various local accumulations of filth, 
of one kind and another. It is well known that the dreadful 
Philadelphia epidemic of 1793 was referred, for its origin, by Dr. 
Rush, to a quantity of damaged coffee, decaying on one of the 
wharves of the city. The principal argument in favor of this 
opinion is the fact, generally admitted, that the disease most com- 
monly commences in the low, crowded, and filthy quarters of 
yellow-fever cities, lying near the docks and wharves. Thus, the 
Barrio de Santa Maria is usually the hot-bed of the disease in 
Cadiz. In 1795, at New York, the disease was mostly confined 
to the vicinity of Peck-slip, a crowded and filthy locality; 1 and 
the same thing has occurred in other years. Dr. Edward Miller, 
of New York, one of the earliest and most unqualified advocates 
of the agency of filth in the production of yellow fever, says that, 
at the commencement of the destructive epidemic of 1798, in 
that city, between twenty and thirty persons in a small neighbor- 
hood, at the lower end of John street, were suddenly seized with 

1 Hosack's Med. Essays, vol. i. p. 293. 

33 



514 YELLOW FEVER. 

the disease in one night, in consequence of a blast of putrid and 
most offensive exhalations from the sewer of Burling slip. 1 

On the other hand, the agency of this cause is stoutly and 
boldly denied by many observers, and especially by those who 
believe in the contagious property, either qualified or absolute, of 
the disease. The principal objections to this doctrine are these. 
In the first place it is asserted, and not denied, that yellow fever 
has sometimes made its appearance, and prevailed extensively, in 
localities quite free from any unusual accumulations of filth, either 
animal or vegetable. In the second place, it is quite notorious 
that, although the disease oftener than otherwise commences in 
filthy localities, still, it very frequently extends to the more airy 
and cleaner neighborhoods. In the third place, if the disease was 
generated from this source, it ought to occur with more regularity 
and constancy; since the alleged cause is always more or less 
extensively present and active, in some portions of all yellow-fever 
cities, and of others where the disease is never seen. It seems 
to me that these objections are quite unanswerable. Yellow fever 
occurred on board the United States schooner Grampus, in 1829. 
Dr. Barrington says : " This vessel was remarkable for her uni- 
form neatness and cleanly appearance throughout. The bilge- 
water smell was seldom perceived; the water coming out of the 
pumps perfectly clear." 2 Several similar instances are mentioned 
by Dr. John Wilson. In 1824, the disease prevailed extensively 
on board the Rattlesnake, a new British ship, on the West India 
station. She had just been thoroughly cleaned. Dr. Wilson 
says: "When the process of purification was considered com- 
plete, I examined every part of the hold's surface, and found it in 
every part, from the hatches to the kelson, clear, clean, and dry, 
scarcely capable of soiling a white glove." It is proper to state, 
however, that in most instances of the occurrence of the disease 
on shipboard, it has been in connection with very damp and filthy 
holds. I do not mean to say that accumulated and concentrated 
filth, acted upon by a high temperature, does not promote and favor 
the origin and spread of yellow fever ; there is good evidence that 
it does so; I mean merely to say that we have no sufficient 
grounds for referring the disease directly and exclusively to this 
cause. 

1 Works of E. Miller, M. D., p. 98. 2 Amer< Joum< Med> Sci Au 1833# 



CAUSES. — CONTAGION. 5l5 

In connection with this subject, it may be mentioned that Dr. 
John Wilson, apparently an attentive observer of yellow fever, and 
generally a sensible writer, is disposed to refer the disease to a 
peculiar kind of ligneous decomposition, for its essential cause. 
He thinks this hypothesis corresponds to all the observed facts in 
connection with the subject, better than any other. 1 I cannot see 
that it is any more plausible or any more reasonable than the 
rest. 

Sec. XV. — Contagion. Let me relieve the friendly and indulg- 
ent reader who has accompanied me, cheerfully and not without 
interest, I would fain hope, thus far, in my history of yellow fever, 
from an apprehension that he may very naturally feel, on be- 
holding the caption of the present section in my manifold chap- 
ter on the etiology of this disease ; — it is not my purpose to oc- 
cupy his time and attention with anything like a history of the 
multiform, complicated, and sometimes bitter controversies, which 
have run through the medical annals of the last fifty years, upon 
the contagious and non-contagious character of the disease. In 
conformity to the general design and arrangement of my book, I 
shall confine myself to a simple statement of the actual and j 
tive condition of our knowledge upon this subject ; all which can 
be done, I think, in the space of a few pages. 

There have been three leading and principal doctrines, or opin- 
ions, upon the question before us, each of which I wish and will 
endeavor to state, together with the grounds upon which it rests, 
as fairly and explicitly as I can. 2 * 

1 Memoirs of the West Indian Fever, p. 139, ct seq. 

2 The great controversy between the oontagionists and thenon-contagionists ori- 
ginated in the following circumstances. ToAvards the close of the last century, a 
project was formed in England for the establishment of a colony — partly benevo- 
lent and partly commercial in its character — on the island of Bulam, or Boullam, 
lying at the bottom of a deep bay, about fifty miles from the open sea, on the 
Western coast of Africa, in the 11th degree of North latitude. Early in the month 
of April, 1792, the ship Hankey, in company with another vessel loaded with stores 
and adventurers, sailed from England for Bulam, where she arrived just before the 
commencement of the rainy season. The Hankey remained at the island nine 
months ; soon after her arrival, a malignant disease appeared amongst her pas- 
sengers and crew, consisting of more than two hundred persons, three-fourths of 
whom were its victims. Aided by a few seamen procured from other ships, the 
Hankey finally sailed for the West Indies, and arrived at Grenada on the 19th of 
February, 1793. According to Dr. Chisholm, the first person who visited the 



516 YELLOW FEVEK. 

The first of these v doctrines is that which attributes to yellow 
fever an absolute and unqualified contagious character. The ad- 
vocates of this doctrine allege, that the disease is directly and im- 
mediately transmissible from one person to another, like measles or 
smallpox. Dr. Chisholm, one of the earliest and most zealous 
promulgators of this doctrine, thus states the leading circum- 
stances which influence the action of the contagious poison ; — 
those who most carefully avoid houses where the infection is, are 
the most certain to escape the fever ; although the disease may be 
in the same house, avoiding the chamber of the sick prevents infec- 
tion ; merely entering the chamber of the sick, without nearly 
approaching the diseased person, has never communicated infec- 
tion ; approaching near enough to the diseased person to be sen- 
sible of the fetor of his breath, or of the peculiar smell which is 
always emitted from the bodies of the sick in this disease, or 
touching the bedclothes, generally occasions nausea, slight rigors, 
and often headache at the moment, and, some hours after, the dis- 
ease itself; actual contact, so that the perspired fluid of the sick 
person may adhere to the hands or other parts, of the healthy 
person, more certainly produces the fever ; touching the wearing 

Hankey, on the evening of her arrival, was a Captain Remington; and in a few 
days afterwards, he died with yellow fever. The crew of the Defiance were the 
next who visited the Hankey ; five out of six were immediately seized with the fever, 
and died in three days. The disease now began to appear in the other vessels in 
the harbor, and spread successively from one to another, not one escaping. Until 
the middle of April, the disease was confined to the shipping in the harbor ; it then ap- 
peared in a house close to the wharf, where it was introduced, according to Dr 
Chisholm, by a negro woman who took in sailors' clothes to wash. The disease 
then extended to different parts of the town, and during the months of May, June, 
and July, it appeared at various points in the neighboring country, carried thither, 
says Dr. Chisholm, by persons who had imprudently visited infected houses in town. 
From Grenada, as from a focus, this nova pestis — this new Malignant Pestilential 
Fever of Dr. Chisholm, spread to the other islands, to Jamaica, St. Domingo, and 
to Philadelphia — the infection being generally carried from place to place in the 
woollen jackets of deceased sailors. — Chisholm 7 s Essay, vol. i. p. 102, et seq. Dr. 
Chisholm attributes the introduction of the disease into Philadelphia, not to the 
damaged coffee, but to some sailors sick with yellow fever, on board the same 
vessel that brought the coffee, as part of its cargo. — Ibid., vol. i. p. 220. Dr. 
Chisholm, it is important to state, looked upon this fever as quite unlike the or- 
dinary remittent yellow fever, as he called it, of the West Indies ; the latter, he ad- 
mitted, was of domestic origin, arising from miasmata, endemic, and not conta- 
gious. The former, he says, may have owed its production, in some instances, to 
the united action of pestilential contagion and the miasmata of marshes, and other 
direct causes of yellow remitting fever. — Ibid., vol. i. p. 208. This is the doctrine 
of contingent contagion, of which I shall speak more fully by and by. 



CAUSES. — CONTAGION. 517 

apparel of a person who is actually diseased, or lias just reco- 
vered from the disease, as certainly communicates the infection 
to the healthy person, and finally, merely passing a person in- 
fected, or who wears the clothes he had on during the existence 
of the disease, in such a manner that the effluvia proceeding from 
them may be blown on the healthy person, has produced the 
disease. 1 

It may be interesting to my readers, while it will best illustrate 
the subject before us, to be made acquainted with some individual 
facts which tend to support the above-mentioned doctrine. Sir 
Gilbert Blane, in a letter to the Hon. Rufus King, relates the fol- 
lowing occurrence. "On the 16th of May, 1795, the Thetis and 
Hussar frigates captured two French armed ships from Gauda- 
loupe, on the coast of America. One of these had the yellow 
fever on board, and out of fourteen men sent from the Hussar to 
take care of her, nine died of this fever before she reached Halifax, 
on the 28th of the same month. Part of the prisoners were re- 
moved on board of the Hussar, and though care was taken to 
select those seemingly in perfect health, the dito am spread r<ij>idly 
in that ship, so that near one-third of the whole crew was more 
or less affected by it." 2 It is greatly to be regretted that the cir- 
cumstances thus related, by Blane, like so many others of a simi- 
lar character, should be in many respects so loose and defective. 
The previous history of the Hussar is not given ; we are not told 
upon whose authority the entire narrative rests ; and nothing con- 
clusive is stated as to the real character of the fever on board the 
Hussar. A similar occurrence is related amongst the documents 
submitted by M. Chervin to the Royal Academy of Medicine. 
According to M. Lemarinier, in October, 1808, the French brig 
Paulinurus, of which he was surgeon, attacked and captured, 
near Barbadoes, the English brig Carnation. The yellow fever 
was prevailing on board the Paulinurus at the time. The Eng- 
lish prisoners were most of them placed on board the latter, and 
nearly all of them had the fever. The day after the capture, M. 
Jance, commander of the Paulinurus, at the time mortally sick 
with the disease, was carried on board the Carnation, where he 
died on the following day. M. Lemarinier and a portion of the 
French crew were also transferred to the prize. The yellow fever 

1 Chisholin's Essay, vol. i. p. 309. 2 Blane's Dis. of Seamen, p. 605. 



518 YELLOW FEVER. 

immediately appeared amongst the crew of the Carnation, ivho had 
had no direct communication with the Paulinurus. /Several of 
them died? Matthew Carey says : "Since the first edition ap- 
peared, I have had information from a number of creditable per- 
sons, that the idea that the disorder has not been communicated 
out of Philadelphia, is erroneous. A family of the name of Hop- 
per, near Woodbury, took it from some of our infected citizens, 
and three of them died. A woman in Chester county, who had 
boarded and lodged some of the sick, died of the malignant fever. 
Three people of one family in Trenton, took it from a sick person 
from Philadelphia, and died of it. A negro servant, belonging to 
Mr. Morgan, took up an infected bed floating in the Delaware, 
which spread the disorder in the family, and Mrs. Morgan and 
her girl both died of it. It was introduced by his son from Phila- 
delphia into the family of Mr. Cadwallader, at Abington, some of 
whom died with it. Some others in different places caught the 
infection and died. But the cases of this kind have been ex- 
tremely few, considering the numbers who carried the disorder 
from hence, and died with it in the country." 2 I may dismiss 
this branch of the subject with the remark that cases even of ap- 
parent communication of the disease, directly from one person to 
another, in an uninfected district, and without the aid of fomites, 
are exceedingly rare ; and it may reasonably be doubted whether 
a single such case, of entire and unquestionable authenticity, has 
ever been known. 

The second doctrine upon this subject is in direct and positive 
opposition to the foregoing. Its advocates deny that yellow fever 
is, ever, or under any circumstances, transmissible, by a contagious 
poison, from one person to another. They allege that it is strictly 
endemic in its origin and character, and absolutely non-contagious, 
like ordinary remittent fever. The general ground upon which 
they rest this opinion is the fact, almost universally admitted, 
that the disease, in a pure atmosphere, is manifestly and unequi- 
vocally not communicable from one individual to another. They 
say, further, that the disease can never be traced from one person 
to another, or from one family to another — its extension depend- 
ing upon personal intercourse ; — that its extinction by cold weather 
is an argument against its contagious quality ; and that the incon- 

i Rapport de i'Acad. Roy. de Med., p. 8. a Carey's Account, &c, p. 81. 



CAUSES. — CONTAGION. 519 

sistencies and contradictions which constantly attend the applica- 
tion of this doctrine render it altogether inadmissible. Since the 
beginning of the great controversy on this subject, in 1793, a 
large proportion of observers — both amongst private practitioners 
and writers — at least in the United States and Great Britain — 
have ranged themselves in the ranks of the non-contagionists. 
Amongst the earliest and ablest champions of this doctrine, in 
our own country, were Dr. Caldwell, still living — Dr. Edward 
Miller, Dr. E. H. Smith, 1 and Dr. Rush. Dr. Deveze, 2 how- 
ever, preceded them all; and his merits, in this respect, have 
been most strangely and most unjustly overlooked. 

In the third place, there is a doctrine holding a sort of middle 
ground between the two extreme opinions which I have just 
stated. This has been called the doctrine of qualified or con- 
tingent contagion. It is held under somewhat modified forms by 
its different advocates, but its fundamental principles may be 
thus stated. Yellow fever is a disease which, in a pure atmo- 
sphere, or in an atmosphere not already in some way altered or 
vitiated, is not ordinarily or readily communicated from one per- 
son to another. Again, yellow fever is a disease which is not 
generally of spontaneous or domestic origin in the localities 
where it prevails; at least this is true of many of these localities. 
But in places where the atmosphere has already undergone the 
unknown alteration or vitiation of which I have spoken, prepar- 
ing those who have breathed it for the action of the poison of yel- 
low fever, the introduction of this poison, in the persons of those 
sick with the disease, in the hold of a ship, in fomites, or in any 
other form, will give rise to the disease amongst the inhabitants 
of this locality. The predisposition or liability created by the 

1 Dr. Smith was one of the editors of the Medical Repository. He was one of 
the victims of the New Yoi'k epidemic of 1798. Dr. Miller's brother and biogra- 
pher pays the following tribute to his memory. "Never can the writer of these 
lines forget the funeral of Dr. Smith. It was when the ravages of pestilence had 
become so tremendous as to drive almost every individual from the city who was 
able to fly ; when scarcely any passengers were to be seen in the streets, but the 
bearers of the dead to the tomb ; and when it appeared as if the reign of death 
must become universal ; it was in circumstances such as these, that Doctors Mitchill 
and Miller, accompanied with two or three other friends, bedewed with their tears, 
and followed to the grave, the remains of a young man, in some respects the most 
enlightened and promising that ever adorned the annals of American Science." — 
E. Millers Works, p. lx. 

2 Anier. Journ. Med. Sci., vol. iv. p. 523. 



520 YELLOW FEVER. 

local vitiation of the atmosphere, is spoken of as the combustible 
element or material; the poison of the disease introduced from 
without is spoken of as the spark that lights upon and fires the 
former. Neither of these conditions alone, it is alleged, is suffi- 
cient for the generation of the disease. 1 

The above was an early and a favorite doctrine with some of 
the most distinguished physicians of the city of New York. Dr. 
Seaman, as long ago as in 1795, laid it down, in the following 
terms: "The general cause of yellow fever, as it appeared in 
this city, is what chemists call a tertium quid, neither one thing 
nor the other, but a result of the junction of certain matters 
emitted from a human body laboring under such a disease, with 
the effluvia arising from vegetable substances in a state of putre- 
faction. These putrid effluvia may, possibly, of themselves, 
generate the disease, in persons highly predisposed, and from 
whom, by their assistance, the fatal epidemic may be spread 
through a neighborhood. The spark that has kindled up the 
putrid vapors in certain parts of our city into action, was most 
probably originally introduced from other places. No yellow fever 
can spread but by the influence of putrid effluvia." 2 The same 
doctrine was adopted, and both ably and earnestly advocated, by 
Dr. Hosack. He classes yellow fever with the plague, dysentery, 
and typhus fever; all which, he says, are rarely communicable 
from one person to another, except through the medium of an im- 
pure atmosphere. The yellow fever, he says, was always intro- 
duced into New York from abroad, and then spread through the 
aid and agency of this vitiated local atmosphere. His favorite 
idea is that of a fermentative process, both in the atmosphere and 
in the human body, by which the specific virus of the disease is 
multiplied; the fermentable materials, as he calls them — by 
which he means the unknown vitiation of the atmosphere — and 
the specific virus, being both of them necessary to the produc- 

1 It is proper to state that even Dr. Chisholm, the great champion of the con- 
tagiousness of yellow fever, explicitly recognizes the agency of the predisposing 
cause. It is conceding nothing, he says, to admit that, at the time the infection of 
the malignant pestilential fever of 1793 was imported, something peculiar and 
capable of predisposing the human body to be acted on by its poison existed in the 
air ; or that, in other words, the atmosphere possessed a peculiar constitution. But 
this is true, he adds, of the plague ; and he denies that this constitution is ever 
sufficient, of itself, to give rise to the disease. — Chisholm'' 's Essay \ vol. i. p. 286. 

2 Med. Rep., No. 3, Art. 2. 



CAUSES. — CONTAGION. 521 

tion of the disease. Dr. Hosack's precise notion seems to be 
this — that the virus introduced into the local atmosphere, already 
vitiated with his fermentable materials, excites and sets up in this 
atmosphere an assimilative process, by which the specific poison 
is indefinitely multiplied — and after this assimilative process has 
taken place, the medium has been created through which the 
disease may be transmitted from one person to another. He al- 
leges, however, that, in a few rare instances, yellow fever has 
been communicated directly from the sick to the well, in a pure 
atmosphere. 1 Dr. Hosack does not believe that animal and vege- 
table decomposition or filth alone, with all the accessories of 
heat, moisture, and a stagnant atmosphere, is sufficient ordinarily 
to generate the disease. 

The qualified doctrine of contagion is more or less admitted, I 
think, by nearly all the contagionists. Sir James Fellowes says: 
" The facts recorded in the preceding reports show that the 
disease was highly contagious in Spain ; but this property seemed 
to depend on a certain temperature which is necessary to the ex- 
istence of the disorder, and a combination of circumstances 
connected with individual predisposition and the climate, which, 
although difficult to define, may be comprehended by those who 
have resided in that country, and who have studied the character, 
habits, and mode of life of the inhabitants." 2 

There are some of the non-contagionists, also, who admit at 
least the possibility of this occasional and contingent contagion. 
Mr. Doughty, a very decided and earnest non-contagionist, says : 
" I am not prepared to say, whether a great number of persons, 
laboring under yellow fever in its violent form, and crowded into 
an ill-ventilated apartment, or circumscribed space, as on board 
ship, might not create a morbid atmosphere, of power sufficient 
to produce fever sui generis. At least, the atmosphere, impreg- 
nated with a general cause, might be rendered more virulent by 
the accumulated effluvia arising from numerous bodies laboring 
under the disease. As, for instance, a person exposed to the 
exhalation from the earth, or any other miasma, which has created 
fever in several, but whose susceptibility to its influence being 
less has escaped, may, by the further exposure to the accumu- 

1 Hosack's Med. Essays, vol. i. p. 253, et seq. 

2 Reports, etc., by Sir J. Fellowes, p. 402. 



522 ' YELLOW FEVER. 

lated effluvia of many bodies affected with the disease, have 
febrile action produced. 1 Dr. Robert Jackson, another non-con- 
tagionist, thus speaks of the same subject. "I hold it to be 
proved, by the histories here alluded to, that fevers, except those 
specifically contagious, rarely propagate from person to person 
in tropical climates, but I do not deny the possibility of the con- 
tingence. If men, either in health or sickness, be crowded into 
damp and ill-ventilated apartments, particularly in bomb-proofs, 
as sometimes happens in time of war from conditions of service, 
or in time of peace from want of barrack-room, the air is con- 
taminated by the emanations of a crowd of inhabitants.'' A 
material, Dr. Jackson thinks, may thus be contingently generated 
possessing the power of self-propagation. 2 In another place he 
says that, in this way, " contagion may sometimes be engrafted 
on the epidemic stock." Even Dr. Rush, one of the most 
strenuous advocates of the domestic origin of yellow fever, admits 
also that the poison may sometimes be introduced from abroad. 
At least he records, without any qualifying remarks, several such 
instances. The fever of 1797, at Philadelphia, he says, was 
derived from the foul air of a ship which had just arrived from 
Marseilles. A ship from Hamburg, he adds, communicated the 
disease, by means of her foul air, to the village of Kensington. 3 
This particular form or modification of the doctrine of conta- 
gion has been recently revived, if I may so speak, in our own 
country. It has been advocated with earnestness and ability by 
Dickson, Strobel, Monette, and others, and at least with a certain 
degree of success, since it has given rise in some instances to 
quarantine regulations. It is a point in the history of yellow 
fever of great interest and importance, to be finally settled 
only by careful and repeated observations, and my notice of it 
would justly be considered imperfect without some of the evidence 
on which the opinion rests. Amongst this evidence, are a con- 
siderable number of individual facts, like the following. In June, 
1823, a Spanish brig sailed from Havana to Passages, a small 
secluded seaport on the shores of the Bay of Biscay, consisting 
mostly of a single street, placed as it were on a shelf of scarped 
rock, and so narrow that it does not admit of the passage of 

1 DougMy's Observ., p. 209. 

2 Jackson on Febrile Diseases, vol. i. p. 31. 

3 Rush's Med. Inq., vol. iii. p. 3. 



CAUSES. — CONTAGION. — FOMITES. 523 

carts or horses ; while the rock forming the hasis of the mountain 
is in some places literally in contact with the houses, which are 
badly ventilated, filthy, dark, and crowded. The vessel arrived 
on the 3d of August. On the 15th, a custom-house officer, who 
had been several days on board, and who was said to have been 
much engaged in the hold, looking after contraband goods, was 
taken ill, and died on the third day, with black vomit. On the 
22d, a man who had been down for some time in the hold survey- 
ing the ship's timbers died. Some of the planks of the \< 
having been found decayed, twelve carpenters were employed in 
removing them, and six of the twelve were attacked in quick 
succession. The opening in the side of the ship commenced on 
the 10th, and on the 23d, the disease began to appear in an un- 
equivocal form in the houses close to which she was moored. The 
disease was almost entirely confined to the immediate vicinity of 
the brig. 1 

Dr. Monette has given an account of the occurrence of yellow 
fever at Washington, Mississippi, in the autumn of 1825. This 
was then a small inland town, six miles east of Natchez, contain- 
ing about two hundred and fifty inhabitants, of whom nearly one- 
half were blacks. Its situation is described as elevated, free from 
marshes, free from filth, and the houses not crowded. It has been 
proverbially healthy; and the citizens of Natchez have been in 
the habit of fleeing thither for safety, on the appearance of yellow 
fever in their own city. Towards the last of August 1825, cases 
of the disease were officially reported in Natchez, and a great 
many merchants crowded into Washington, carrying with them 
household furniture and all kinds of £oods and groceries. Several 
deaths soon took place in Washington, amongst the fugitives from 
Natchez. Ten or twelve days after the flight from Xatchez, 
deaths from yellow fever began to occur amongst the inhabitants 
of Washington. Two of the persons, amongst those first attacked, 
lived together in a house entirely isolated, two hundred yards 
from the main street, in an elevated and clean spot ; they were 
carpenters, and had been at work shelving rooms for the merchants 
from Natchez, and assisting them in opening and putting up their 
goods. The disease was malignant; cases occurred in all parts of 
the town, and the people from Natchez again fled, accompanied 

1 Cyc. Prac. Med., vol. ii. p. 292. 



524 YELLOW FEVER. 

by the citizens of Washington, to the surrounding country. One 
fourth of the white population fell victims to the epidemic. Dr. 
Monette asserts that, in several well-ascertained instances, cases of 
the disease occurred in the surrounding country, in persons who 
had not been in Washington, but who had been exposed to the 
blankets and bedding of those who had died of the disease. The 
most striking case of this character is thus stated. "At a gentle- 
man's house, two miles from Washington, two of his relations, 
after being removed thither, died of yellow fever. The bedding 
on which they had lain was thrown together into an upper room, 
where it remained several days. In this place it was found by 
three small girls, who for two or three days, unknown to their 
parents, where in the habit of going into this room to play upon 
the bedding. In a short time all three of these children were 
attacked with well-marked yellow fever, although the situation 
has been noted for its salubrity, and they had no opportunity of 
contracting the disease elsewhere. These were the only persons 
in the family who suffered from the disease." 1 These cases of Dr. 
Monette's seem to have been mostly referable to the action, not 
of direct personal contagion, but to that of fomites. This con- 
stitutes a local concentrated atmosphere of the poison ; and there 
is the most ample and conclusive evidence that it may be pre- 
served for a long period of time in this way. 2 

Sec. XVI. — Exposure; Fatigue; Excesses, $c. There can be 
no doubt that yellow fever is frequently the immediate result of 
the operation of the ordinary occasional or exciting causes of dis- 

1 West. Med. and Phys. Journ., vol. i. p. 73, et seq. 

2 It seems to have been forgotten, that even Dr. Rush distinctly admitted the 
possibility of this origin of the disease. He says : " It is possible a portion of 
the excretions of the sick may be retained in beds or clothes, so as to afford an 
exhalation that may in the course of a succeeding summer and autumn, or from 
accidental warmth at any time, create a solitary case of fever, but it cannot ren- 
der it epidemic. A trunk, full of clothes, the property of Mr. James Bingham, 
who died of the yellow fever in one of the West India Islands, about fifty years 
ago, was opened, some months after it was received by his friends, by a young 
man who lived in his brother's family. This young man took the disease and 
died ; but without infecting any of the family ; nor did the disease spread after- 
wards in the city. The father of Mr. Joseph Paschall was infected with the 
yellow fever of 1741, by the smell of a foul bed in passing through Norris's Alley, 
in the latter end of December, after the disease had left the city." — Rush's Inq., 
voL iii. p. 103. 



CAUSES. — EXPOSURE. — EXCESSES. ETC. 525 

■: and that persons exposed to the essential poison of the dis- 
might escape, were it not for the co-operation of the latter 
influences. Still, it must be admitted that the extent to which 
these causes act, in the production of the disease, has been only 
very loosely studied and very imperfectly ascertained ; and. in 
many instances, the power of the endemic cause is so great and 
so overwhelming as to stand in need of no assistance from acci- 
dental or collateral agencies. Dr. Barrington says from all he 

seen, he is convinced, that the temperate man, as a general 
rule, has the best chance ; but he say.-, also — and these are his 
w<»rd- — "I have not observed that those who were accustomed 
to the regular and moderate use of spirituous drinks, were more 
obnoxious to attacks of fever, than others of rigidly temperate 
habits; on the contrary, and I regret to say it, because it affords 
a pretext for the intemperate, in two or three instances. I have 
seen the abstemious carried off in a few days, while hard drink- 
ers, under the same exposure, have escaped/' 1 Dr. Rush, in his 
account of the fever of 1803, in Philadelphia, says : "I did not 
see a single case in which the disease came on without an excit- 
ing cause; such as light clothing and bedclothes, sitting at doors 
after night, a long walk, gunning, and violent and unusual exer- 

3 of any kind." 2 This observation would be of more value 
than it is. if Dr. Rush had been somewhat more careful and dis- 
criminating than he was, and less ready to jump blindly to gene- 
ral conclusions. Dr. Hillary — that honest and careful old obser- 
ver — says: "'The disease most readily seizes those who use vinous 
or spirituous liquors too freely ; and still more readily, those who 
labor hard, or use too violent exercise, and are at the same time 
exposed to the influence of the scorching rays of the sun in the 
daytime, and soon after expose themselves too suddenly to the 
cool dews, and damp air of the night, and especially if they drink 
spirituous liquors too freely at the same time." 3 

Sir Gilbert Blane. speaking of acute diseases generally, amongst 
Europeans newly arrived in the West Indies, says : ** It cannot 
be too much inculcated on those who visit tropical countries, that 
exercise in the sun, and intemperance, are most pernicious and 
fatal practices, and that it is in general by the one or the other 

1 Am. Journ. Med. ScL, Aug. 1833. - Med. Inq.. vol. it. p. 58. 

3 Rush's Hillary, p. 107. 



526 YELLOW FEVER. 

that the better sort of people, particularly those newly arrived 
from Europe, shorten their lives." 1 Matthew Carey says of the 
Philadelphia epidemic, of 1793:' " To tipplers and drunkards, 
and to men who lived high, and were of a corpulent habit of body, 
this disorder was very fatal. Of these many were seized, and 
the recoveries were very rare." 2 Dr. Dev&ze, in his account of 
the same epidemic, says it has always been remarked that, during 
the prevalence of yellow fever, persons newly married are con- 
stantly its victims. 3 " Of all the exciting causes of yellow fever," 
says Bally, a the act of coition is the most powerful; how many 
have we seen, seized by a chill on leaving the arms of Pleasure, 
terminate in a few days their career ! How many even have we 
seen the victims of a simple nocturnal pollution !" 4 

Sec. XVII. — Essential Poison. In regard to the essential poi- 
son, the application of which to the system gives rise to yellow 
fever, I can do but little more than to repeat the remarks that 
have already been made in connection with the essential etiolo- 
gical poisons of other fevers. The nature and composition of 
the former, like those of the latter, are entirely unknown to us. 
It would seem to be clearly enough of terrestrial origin ; and not 
capable of being transmitted, to any considerable distance, through 
the atmosphere. Most of its ascertained properties and relations 
have already been indirectly stated ; inasmuch as they are con- 
nected with the causes of yellow fever already detailed. It is 
quite unnecessary, and it would be a very thankless and unpro- 
fitable labor, to enumerate the successive hypotheses and specu- 
lations which have been started in regard to the origin, nature, 
and mode of action of this poison. The animalcular or crypto- 
gamous hypothesis seems to me more plausible and less refractory 
than the others ; but it is only a pure hypothesis. As to its mode 
of action on the system, the organs by which it is received, and 
so on, we are as profoundly ignorant as we are of its nature and 
composition. It is probable that it is introduced into the system 
through the lungs ; although this is merely a conjecture. It is en- 
tirely philosophical, to consider it as a peculiar poison — an agent 
sui generis — differing from all others, like the essential poison of 
smallpox, hydrophobia, and so on. A very short exposure to 

1 Diseases of Seamen, p. 132. 2 A Short Account, etc., p. 61. 

3 Deveze, p. 114. 4 Du Typhus d'Amei'ique, par Vr. Bally, p. 375. 



CAUSES. — ESSENTIAL POISON. .027 

its influence is sufficient to produce the disease ; it is very pro- 
bable that a single inhalation is enough. It may be retained for 
a considerable period of time shut up in the holds of vessels, in 
trunks or bales of clothing, in bedding, and even in apartments 
of houses, "while the surrounding atmosphere is free from it ; in 
some of these forms it may be transported long distances from 
the place of its origin, and there give rise to the disease. The 
only known means of destroying it consists in a temperature as 
low as the freezing point, and this is always immediate and com- 
plete in its operation. 



528 



CHAPTER* V. 

VAEIETIES AND FORMS. 

Sec. I. — Season and Locality. Yellow fever is not exempt from 
that very general law of pathology according to which endemic 
and epidemic diseases, especially, vary more or less widely in 
severity, and sometimes in other respects, in different periods 
and in different localities. Sometimes and in some places the 
general character of the disease is mild and the mortality small, 
at others it is grave and malignant and the mortality excessive. 
The disease varies also in other respects, in different seasons and 
places, sometimes one element or tendency and sometimes an- 
other in its complex pathology predominating. Thus the pre- 
vailing character of the disease may be, during one season, 
simple and mild; during another, violent and inflammatory; and 
during a third, adynamic and congestive. Similar differences 
have also been observed at different periods of the same epi- 
demic, in a given locality. It is a common opinion, indeed, that 
the commencement of an epidemic is usually marked by greater 
malignancy and severity than its subsequent periods. The causes 
of these fluctuations and differences in the severity and character 
of the disease are wholly unknown to us ; there are no obvious 
or appreciable influences to which we can attribute them ; and in 
the absence of all positive knowledge upon the subject, we are 
obliged to refer them to unknown and hypothetical constitutions 
of the atmosphere, and to differences in the quantity or quality 
of the essential remote cause of the disease. It is proper to say 
here that, although there can be no doubt about the existence of 
these differences, still, their extent, degree, and frequency, have 
been less carefully studied, and less positively ascertained, than 
many other points in the natural history of this disease. There 
are, however, in addition to the general opinions of those who 
have been most extensively familiar with the disease, numerous 



VARIETIES AND FORMS. 529 

well ascertained and authentic facts bearing upon the question 
before us. 

Sec. II. — Forms, or Grades. Different writers upon yellow 
fever have divided the disease into forms, or varieties, more or 
less numerous, depending upon different degrees of severity, or 
upon the preponderance of certain groups of symptoms. The 
most common, and I think the most natural of these groupings, is 
that which makes three forms or varieties of the disease, to wit: 
First, the Simple or Mild form ; Second, the Inflammatory form ; 
Third, the Congestive, or Malignant form. This subdivision is 
of course to a certain extent arbitrary and conventional ; still, 
it is founded in nature, and it is both useful and convenient, on 
many accounts, in the description and history of the disease. It 
corresponds very nearly to the similar divisions in other epidemic 
diseases ; — to the simple, the anginose, and the malignant forms, 
for instance, of scarlet fever. 

The simple or mild form of yellow fever is marked by the 
smaller number of symptoms than are present in the graver 
cases, and by their very moderate degree of severity. Most writ- 
ers make particular mention of this variety of the disease ; and 
it is very common during certain epidemics. Louis describes it 
in the following terms : " Most commonly, at the commence- 
ment, there were headache, chills followed by a slight degree of 
heat, pains in the limbs, and redness of the face and eyes. The 
epigastric pains were rare, and so too were the vomitings, which 
were almost never spontaneous, and which in no case were of a 
brownish color. The heat and thirst were moderate, and so slight 
was the diminution of strength, that the patients did not keep 
their beds at all, or were there for half a day only ; thus, accord- 
ing to their expression, going through with the disease on foot. 
In this form of the disease, they were able to escape the vigilance 
of the health inspectors, resuming familiar occupations, or play- 
ing on musical instruments, when these last made their visits. 
In several of these cases, the febrile symptoms were very slight, 
continuing only during twenty-four or thirty-six hours." 1 Dr. 
Lewis, of Mobile, says : " The attacks in the milder cases were 
occasionally so light and ephemeral, as to pass off in a few hours, 

• Louis on Yellow Fever, p. 175. 

34 



530 YELLOW FEVER. 

leaving the patient with some soreness of the muscles, and slight 
pain in the hips and legs. But, as a general rule, they confined 
the patient to his bed for three or four days. After the chill, 
which was commonly of very short duration, the pain over the 
eyes, and in the back and hips, became for a short time intense. 
The flushed face, animated voice, and sparkling eye, which char- 
acterized the febrile stage, have been aptly compared to the ex- 
citement produced by champagne. In a few days the disease 
has run its course, and after it has done so the patient is well ; 
with a gentle perspiration, the momentary fretting of the nervous 
system passes rapidly away, without materially impairing or dis- 
turbing any of the organs." 1 These mild cases occur most fre- 
quently amongst children, negroes, and natives, or those who 
have become more or less acclimated. During the prevalence of 
yellow fever at Gibraltar, in 1828, several persons, amongst whom 
were some of the medical practitioners, took pains to expose their 
children to the causes of the disease, in order to secure them 
against graver attacks later in life. Dr. Gillkrest says, in epi- 
demics of ordinary severity, such mild cases may occur in the 
proportion of one to ten or twelve of the severer grades ; and 
their occurrence will usually be found more frequent as the end 
of the epidemic season approaches. 2 

The open inflammatory form, as its name indicates, is charac- 
terized by the phenomena of frank febrile excitement. The local 
pains, especially those of the head, back, and limbs, are violent ; 
the skin is warm, the pulse full and hard, and the thirst urgent. 
These symptoms continue for a day or two, and then gradually 
subside, giving place to convalescence ; or they are followed by 
the stages of calm and collapse, terminating in death. 

In the congestive or malignant form of yellow fever, the febrile 
excitement of the first period is either wanting, or only slightly 
marked ; or, if present in any considerable degree, it is accompa- 
nied by certain phenomena indicative of the congestive element, 
and is soon followed by the gravest and most alarming symptoms 
of the disease. There seems to be a good deal of variety in the 
character of these cases. Sometimes the disease is in some de- 
gree latent — its usual symptoms being either masked or absent. 
The walking cases, as they are called, belong to this variety. At 

1 N. 0. Med. Journ., vol. i. p. 295. 2 Cyc. Prac. Med., vol. ii. p. 270. 



VARIETIES AND FORMS. 531 

other time3, the disease is marked by a want of reaction, softness 
of the pulse, coldness of the surface, great restlessness and dis- 
tress, a tendency to hemorrhage from different parts of the body, 
and rapid collapse. 1 

1 Dr. John Wilson divides the disease into inflammatory and congestive; he then 
makes three grades of the former — the mild, the violent, and the intense; and 
three of the latter ; the slight, the aggravated, and the apoplectic. These varieties 
are thus described. " The most constant and prominent symptoms of the inflam- 
matory were with, or without rigor, frequency and strength of pulse, wiry, com- 
pressed, or full; a hot, non-secreting condition of the skin, particularly at theprse- 
cordia, and across the forehead ; headache, confined generally to the sinciput, with 
sense of fulness in the eyes, and tightness between the temples; jactitation, and 
constant rolling or otherwise moving of the head; flushing of face, with promi- 
nence, wildness, and sometimes inflammation of the eyes ; pain in the back and 
loins, shooting across the anterior parietes of the abdomen involving the whole 
contents in tumult." With these symptoms there were also insatiable thirst ; high- 
colored and scanty urine ; and in some cases abdominal tension and tenderness in 
the early stages, followed by a sense of emptiness and exhaustion there as the 
disease proceeded. 

In the intense form he says : " The action of the carotids was tremendous : the 
face red, and frenzied in expression; the eye sometimes clear, quick, 'and piercing: 
sometimes dull, and darkly inflamed, always indicative of great cerebral derange- 
ment. The skin had an intensity of heat scarcel}' conceivable, particularly on the 
breast, neck, and head. The tongue was parched, hot, and apparently diminished 
in size." 

Of the congestive form he says : "A sense of stupor, weight, and oppression, rather 
than pain in the head; a feeling of helpless debility, affecting the spine, most dis- 
tressing about the sacrum ; a paralytic failure of the lower extremities, with pains 
in the knees and calves of the legs ; a pulse having all degrees of celerity ami ex- 
pansion, but always weak, sinking under the finger without resistance : a state of 
the skin various and difficult to define, but always deficient in tone, sometimes dry 
and dense, sometimes greasy, and sometimes drenched in sweat ; generally without 
iucrease of heat except at the prascordia, where it was confined and smouldering: 
a most distressing expression of countenance, deadly pale or livid in color : a 
drunken idiotic eye, with dilated pupil and sleepy motion ; deafness ; desire to be 
left alone ; sighing, deep and interrupted ; early tendency to coma ; tension of the 
hypochondria, and early irritability of stomach, were the principal symptoms by 
which this division of the disease was characterized." 

The highest grade of the congestive form is thus described : "The attack was 
like the effect of electricity. In an instant, its subject was seized with giddiness, 
dull pain of head, and confusion of ideas ; a sense of coldness, weakness, and in- 
describable uneasiness along the spine : spasmodic pains in the legs, and paralytic 
incapacity of the lower extremities. He lay as if stunned, and laboring under 
concussion of the brain, with dilatation of the pupils, and a gloomy despairing 
countenance. The pulse was rapid or slow, full or small, but always weak. The 
skin was cold, generally greasy, or covered with cold liquid sweat, sometimes 
dry and lifeless." 

"There is a modification of congestive fever so insidious as to give little alarm, 



532 YELLOW FEVER. 

Some writers have gone much further than this, and have alleged 
that several distinct diseases, or forms of disease, have been con- 
founded under the common name of yellow fever. The opinions 
of Chisholm upon this point are well known. Bally proposes to 
admit one species which is contagious, and another which is non- 
contagious. Dev&ze says, very properly, I think, in regard to 
these and all other like distinctions, that they are arbitrary and 
unfounded. 1 

and lead the inexperienced to think the patient is in no danger. The person labor- 
ing under this form of disease will confess, on being sharply questioned, that there 
are slight pain and heaviness in the head, and the epigastrium is tender on pressure. 
Otherwise little appears to be the matter, the pulse being natural, or so nearly natu- 
ral as to escape observation ; the tongue clean ; the skin cool or obscurely hot over 
the stomach and liver ; the eye clear ; and the entire aspect, to superficial observa- 
tion, promising. Yet, in less than forty hours, the surgeon will be alarmed and 
confounded by black vomiting, soon followed by death. Although the patient will 
say, every time that he is visited, that he is better, and that, could he only eat, he 
would be well ; on looking closely, it will be perceived that his answers do not 
always bear on the questions put; that amid his account of improvements, he never 
attempts to lift his head from the pillow till desired, and hurriedly lets it down 
again; that he dozes rather than sleeps, sighs frequently, and has difficulty in 
filling the lungs ; and that the eye, though clear, is vacant, or fixed without an ob- 
ject." — Memoirs of the West Indian Fever, p. 8, et seq. 
1 Traite de la Fievre Jaune. Par Jean Deveze. 



533 



CHAPTER VI. 

MARCH AND DURATION. 

Sec. I. — March, or Type. Yellow fever does not belong to the 
class or family of periodical diseases; it is not properly remittent, 
nor intermittent, in its type; it is not marked by any obvious and 
regular sernes of recurrent phenomena. The periodical element 
in pathology may sometimes be engrafted upon it, or mixed up 
with it, as happens occasionally with other diseases; but the two 
affections are essentially and fundamentally dissimilar. Upon 
this point most modern observers, I believe, are agreed, although 
many of the older writers maintained an opposite doctrine. This 
was the case especially with those who were zealously contending 
for the domestic and miasmatic origin of the disease. They 
conceived the cause they were advocating to be strengthened by 
every analogy and resemblance which they could discover be- 
tween the two forms of disease; and this influence led many of 
them to adopt the doctrine that yellow fever is only an aggra- 
vated form or a Mgli grade, as they call it, of ordinary remittent 
fever. It is well known that this was the opinion of Dr. Rush. 
He says that, in every case of the disease which came under his 
notice, there were remissions or intermissions of the fever, or of 
such symptoms as were substituted for the fever, generally occur- 
ring in the forenoon, and that these remissions were more evident 
than in the common bilious fever. I think, however, that a care- 
ful estimate of Dr. Rush's remarks upon this subject, with the 
aid of subsequent and more accurate investigations, will lead to 
the conclusion that his observations are not to be trusted. His 
description of the remissions is anything but clear and distinct ; 
and when we take into consideration the extent to which his 
judgment was perverted, and his vision blinded, by his prepos- 
terous dogma of the unity of disease, it can hardly be considered 



534 YELLOW FEVER. 

unreasonable, if, in the settlement of this question, we set his 
opinions wholly aside. 1 

I have just stated that yellow fever, like other diseases prevail- 
ing in malarious regions, may sometimes assume something of a 
periodical character. This subject, deserving of further investi- 
gation, has recently been studied by Dr. Lewis, of Mobile. 

He has described a form of the disease which he calls remit- 
tent and intermittent yellow fever. During the epidemic of 1843, 
at Mobile, simple remittent fevers prevailed extensively in the 
southern part of the city, mostly amongst the native and accli- 
mated population. Dr. Lewis says that he attended, in this 
district of the city, sixteen cases of remittent or intermittent 
fever, assuming the rank and grade of yellow fever. These 
cases were all amongst the unacclimated. Dr. Lewis estimates 
the number of these cases, during the epidemic of 1843, at one 
hundred; fifty of which terminated fally. He says the intermit- 
tents were more fatal than the remittents. With the exception of 
this periodical element, the disease in these cases did not differ 
from the ordinary unmixed forms of yellow fever ; it went regu- 
larly through its several stages, and terminated in its usual 
manner, and at its usual periods. Of twenty-eight cases of fatal 
intermittent yellow fever, all terminated within the seventh day 
from the initial chill. 2 Dr. Lewis does not give any full descrip- 
tion of these cases, but there is no reason whatever for doubting 
the correctness of his conclusions. He is a competent and trust- 
worthy observer, and he is in no way influenced in his opinions 

1 Nowhere, perhaps, does Dr. Rush make a more absurd exhibition of this 
favorite article of his philosophical creed, than in connection with the subject of 
the text. "Science," he says, "has much to deplore from the multiplication of 
disease. It is as repugnant to truth in medicine, as polytheism is to truth in 
religion. The physician who considers every different affection of the different 
systems in the body, or every affection of different parts of the same system, as 
distinct diseases, when they arise from one cause, resembles the Indian or African 
savage, who considers water, dew, ice, frost, and snow, as distinct essences ; while 
the physician who considers the morbid affections of every part of the body, 
however diversified they may be in their form or degrees, as derived from one 
cause, resembles the philosopher who considers dew, ice, frost, and snow, as dif- 
ferent modifications of water, and as derived simply from the absence of heat. 
Humanity has likewise much to deplore from this paganism in medicine. The 
sword will probably be sheathed forever, as an instrument of death, before phy- 
sicians will cease to add to the mortality of mankind by prescribing for the names 
of diseases." 

2 N. 0. Med. and Surg. Journ., vol. i. p. 292. 



MARCH AND DURATION. 535 

by preconceived prejudices or notions, since he recognizes, with- 
out any qualification, the essential dissimilarity of periodical and 
yellow fever. In another paper, Dr. Lewis mentions particularly 
seven cases, occurring in 1842, which he calls congestive, a i inula- 
ting yellow fever. They occurred in persons who had been living 
in malarious regions, and were marked by the symptoms of con- 
gestive and of yellow fever. Dr. Lewis says: "The pathological 
appearances of the congestive fever of the interior, and the yel- 
low fever of Mobile, were both apparent in these cases, so that, 
taken in connection with the symptoms before death, they consti- 
tuted a perfect example of the blending together of the different 
febrile poisons, so as to produce a disease of mixed character." 1 
Other diseases are frequently mixed up with this periodical ele- 
ment in pathology : and not only is there no reason, a priori, 
why such should not sometimes be the case with yellow fever, 
but it would be a very singular circumstance if this disease alone 
should be exempt from this complication. 2 

It is hardly necessary to say that the distinction which Chis- 
holm attempted to establish between what he called Malignant 
Pestilential Fever, and the Yellow Remittent Fever of the West 
Indies was wholly gratuitous and unfounded. Lempriere, also, 

1 N. 0. MecL Journ., vol. i. p. 35. 

2 1 find, since writing the above, that Lempriere, towards the close of the last 
century, noticed particularly this modification of yellow lever in Jamaica. He 
calls it "a variety of the disease (/rafted upon the remittent." "In this."" he 

" the first attack is marked by the usual symptoms which usher in the remittent, 
except that the affection of the head is more severe, and the eyes wear a suspi- 
cious appearance; remissions and exacerbations proceed alternately as in the com- 
mon remittent, and bark in large doses is generally retained during the remissions, 
from which the inexperienced are wont to draw favorable conclusions: but about 
the third or fourth day, and sometimes later, such symptoms occur as denote the 
greatest danger; the eye becomes muddy and suffused, the countenance despond- 
ent, and the neck, and afterwards the whole body, shows itself dyed with a yellow 
suffusion; great irritability of stomach, and oppression about the precordia, 
delirium, or more frequently coma, and many other symptoms of the genuine 
yellow fever, supervene." — Observations, etc.. by Lempriere, vol. ii. p. 70. Dr. 
Dickson, of Charleston, S. C, admits explicitly and distinctly the existence of this 
modified form of yellow fever. "In the summer of 1817," he says. " many northern 
and foreign sailors had been induced to go as boatmen up our rivers. Consider- 
able numbers of them were brought into our hospitals with country fevers, both 
remittent and intermittent, which, as soon as yellow fever became prevalent, 
ran into that epidemic — the fever becoming continued, and black vomit ensuing." 
— Dickson s Essays, §c, vol. i. p. ooo. 



536 YELLOW FEVER. 

admitted the existence of a distinct disease, in the West Indies, 
usually showing itself in crowded ships, partaking of the charac- 
ter both of yellow and typhus fever, and, like the latter, conta- 
gious. It seems to me quite clear, that this disease was only the 
malignant or congestive form of true yellow fever. 1 

Sec. II. — Stages. But although there is no regularly recur- 
rent or periodical element in yellow fever, the disease, in fatal 
cases, is marked by several very constant and striking stages, or 
periods, through which it passes with great regularity. These 
stages, or periods, are three in number, to wit : first the febrile 
period, or the stage of excitement; second, the passive stage, or 
remission, or the stage of calm, as Dr. Lewis calls -it; and third, 
the stage of collapse. The first stage is marked by general 
febrile excitement, and it passes into the second with an abate- 
ment of the severity of the local pains, and of the fever. The 
second stage is marked, in addition to the change of symptoms 
just spoken of, by epigastric distress, nausea, and vomiting, and 
general restlessness, the latter commonly paroxysmal. The 
third stage usually commences with the black vomit, and is 
immediately followed by coldness of the extremities, yellowness 
of the surface, general sinking of the powers of life, and speedy 
death. In grave cases, terminating favorably, the period of 
remission, instead of passing into the stage of collapse, is followed 
by convalescence; and in the milder forms of the disease, it can 
hardly be said that there are any of the distinct stages, except 
the first. Dr. Lewis says : " The collapse stage is more marked and 
regular some years than others. In 1837, it was irregular; in 
1839, it seldom failed to occur on the night of the fourth day, 
attended with immediate and striking evidences of sinking pros- 
tration ; in 1843, it occurred between the beginning of the fourth 
and sixth day of the disease." 2 The duration of these several 
stages will be found, of course, to vary considerably in different 
cases and under different circumstances. The most positive in- 
formation that I am able to find upon this point is derived from 
Dr. Lewis. " I have taken," he says, " twenty cases of epidemic 
fever, in which all these stages were well defined — the notes of 

1 Observations, etc., by Wm. Lempriere, vol. ii. p. 80. 

2 N. 0. Med. and Surg. Journ., vol. i. p. 298. 



MARCH AND DURATION. — STAGES. 537 

many of them furnished by medical friends — and after a careful 
examination, I ascertained the average duration of each stage to 
be as follows: fever, twenty-two hours, calm, one hundred and 
twenty hours; collapse, fourteen hours." 1 Dr. Lewis says that, 
in the fever of 1847, the febrile stage was considerably longer ; 
running on generally to about three days. Dr. Dickson says 
this stage may pass by in four hours, or it may last for sixty 
or seventy ; its average duration being from thirty-six to forty- 
eight. 2 The three stages of yellow fever are very well described 
by Dr. Chisholm: " The history of the malignant pestilential 
fever," he says, "exhibits a very distinguishing character. 
We see in it a disease dispossessed of alternate paroxysms and 
remissions ; and having in its progress three distinct periods or 
stages: the first characterizing an inflammatory diathesis of a 
peculiar nature, ushered in, generally, by a convulsive afFection 
of the frame, or a sudden morbid excitement of the nervous 
system; the second, a kind of suspension of all the animal func- 
tions, accompanied with a more or less imperfect exercise of the 
mental faculties ; and the third, a general sphacelus of the vital 
organs." 3 Dr. Mosely also makes the same division, and he 
speaks of the "deceiving tranquillity" of the second stage. In 
relation to the treatment, he remarks, that " it is in the beginning 
of this second stage, when attempts have failed or have been 
neglected in the inflammatory stage, that the great struggle is to 
be made between life and death." 3 Lempriere takes pains to 
call the disease a continued fever. Dr. Burnett says: " In many 
instances it proceeds through its whole course, bearing strictly 
the form of a continued fever; in others, there is a deceitful 
remission about the third day. But in by far the greater number 
of cases, though there are evening exacerbations, the remissions 
in the morning are so slight as scarcely to deserve that name. 
The most attentive observation, by myself, and others on whom 
I could rely, has failed to detect the distinct remissions ascribed 
to the disease by Dr. Cleghorn." 5 

According to Bally the duration of the first stage, in cases that 
are prolonged to the seventh day, varies from forty-eight to 

1 N. 0. Med. and Surg. Journ., vol. i. p. 301. 

2 Dickson" s Essays, &c, vol. i. p. 348. 3 Ckisholm's Essay, vol. i. p. 195. 
4 Mosely on Tropical Diseases, p. 436. * Burnett on Med. Fever, p. 10. 



538 YELLOW FEVEK. 

seventy-two hours ; in cases terminating before the fifth day, it 
is less ; that of the second stage is about two days, a little more 
or a little less; and that of the third, from one to two days. 1 

Sec. III. — Duration. Yellow fever is rapid in its progress 
and short in its duration. Perhaps there is no disease, excepting 
contagious puerperal fever, and Asiatic cholera, which terminates 
with such uniform rapidity, either in death or recovery as this. 
Life is sometimes destroyed in three or four days, and the average 
duration of fatal cases is less than a week, the largest number of 
deaths taking place on the seventh day, but many more cases ter- 
minating before this period than after it. Of twenty-one fatal cases, 
reported by Dr. Barrington, death took place on the third day, in 
one ; on the fifth day, in six ; on the sixth day, in three ; on the 
seventh day, in eight ; on the eighth day, in one ; on the thirteenth, 
in one, and on the twenty-eighth, in one. 2 Dr. Lewis says that 
during the epidemic of Mobile in 1843, it was not uncommon to 
hear of persons who were well in the morning and dead at night ; 
but that these reports were always untrue, the disease never de- 
stroying life so rapidly. 

Dr. Barton, in his paper on the yellow fever of New Orleans, in 
1833, gives the period of discharge from the hands of the physi- 
cian in sixty-eight cases of recovery. This period was the second 
day, in four ; the third, in ten ; the fourth and fifth, in fourteen 
each ; the sixth, in ten ; the seventh and eighth, in four each ; 
and after the eighth, in eight. Of forty-four cases, where the 
time of the returns of appetite was ascertained, this took place on 
the second day, in one ; on the third, in seven ; on the fourth and 
fifth, in fourteen each; on the sixth, in seven, and on the eighth, 
in two. 3 The duration of the mild form of the disease is still 
less. 

Sec. IY. — Convalescence. There are but few writers on yellow 
fever who make any special mention of the character or the dura- 
tion of the convalescence from the disease. From their general 
silence upon this point, we might conclude that recovery is usu- 
ally speedy and entire. But Louis says that, in the Gibraltar 

1 Du Typhus d'Amerique. Par Vr. Bally, p. 208, et seg. 

2 Amer. Journ. Med. Sci., Aug. 1833. 3 Ibid., Not. 1834. 



MARCH AND DURATION. — CONVALESCENCE. 539 

epidemic of 1828, the convalescence, both in grave and mild 
cases, was long in proportion to the duration of the disease ; the 
strength of the patient, in severe cases, not being perfectly re- 
established sooner than from ten to twenty days after the cessation 
of the febrile symptoms. 1 Dr. Chisholm says: " As long as the 
patient remained in the infected room or house, although all symp- 
toms of the disease had disappeared, the progress of recovery was 
remarkably slow," but that a removal into the pure air was fol- 
lowed by rapid restoration to health. 2 Arejula, in his description 
of the Cadiz epidemic of 1800, observes, that the debility and 
want of appetite following the disease always remained for some 
time, even after the fever had subsided. 3 These statements are 
corroborated by some tables, published by Dr. Barrington, for the 
purpose of showing the difference in the duration of the disease 
depending upon its treatment. Of seven patients treated on the 
non -mercurial plan, two were fit for duty in eleven days, and the 
others in from twelve to twenty. Of seven treated by mercurials, 
one was fit for duty in twenty days, and the rest in from twenty- 
two to thirty-nine. 4 Deveze speaks of the convalescence as long 
and difficult, requiring all the aids of a good regimen. 5 " Con- 
valescence," says Bally, "is a true malady, which on account 
of profound lesions, and the continuance of consecutive disorders, 
often leaves but feeble hopes ; the senses remain more or less dull ; 
the digestive organs arc feeble ; and to these difficulties are fre- 
quently added, diarrhoea, cachexia, and marasmus." 6 M. Catel, 
M. Chervin, M. Mongez, and others, speak of convalescence as 
nearly always prompt and complete. Dr. Lewis, in speaking of 
the epidemic of Mobile, in 1847, remarkable for its harm- 
less and mild character, says that, although the symptoms all 
subside on the fourth day, the patient is stripped of his strength, 
and can neither take exercise nor sit up for five or six days. 
Dr. Dickson says recovery is generally slow, and convalescence 
tedious and lingering. 7 

Convalescence is often accompanied by excessive activity of 
the sexual appetite. Deveze says he noticed this in both sexes 

1 Louis on Yellow Fever, p. 173. 2 Gkisholm's Essay, vol. i. p. 406. 

3 Reports, etc., by Sir J. Fellowes, p. 53. * Amer. Journ. Med. Sci., Aug., 1833. 
' 5 Traite de la Fievre Jaime. Far Jean Deveze, p. 33. 
6 Du Typhus d'Amerique. Par Yr. Bally, p. 272. 
? Dickson's Essays, &c, vol. i. p. 352, 



540 YELLOW FEVER. 

at Philadelphia, and in St. Domingo. "Delicacy," says Dr. 
Rush, " forbids a detail of the scenes of debauchery which were 
practised near the hospital, in some of the tents which had been 
appropriated for convalescents." 

Sec. V. — Relapses. Relapses seem to be rare ; many writers 
do not mention them at all. Louis speaks of them as sometimes 
occurring, in cases where the disease had been violent, and brought 
on generally by errors of regimen. According to Dr. Gillkrest, 
however, they would seem to be more common. He says that 
there were one hundred and two cases amongst the soldiers at 
Gibraltar, in 1828. 1 Arejula says that at Cadiz, in 1800, re- 
lapses were very frequent and fatal. 2 Dr. Burnettquotes several 
writers who speak of the frequent occurrence of relapses. 

Sec. VI. — Sequelae. It does not appear that yellow fever 
often entails upon its subjects other and subsequent affections, 
either chronic or acute. A few writers, indeed, speak of chronic 
organic disorders, visceral obstructions, as they were formerly 
called, as amongst the consequences of the disease, but in such 
loose and general terms as to deprive their remarks of all value. 
Dr. Burnett says : "The foundation of phthisis pulmonalis is 
often laid by this disease, and the patient, though saved from 
its immediate is destroyed by its remote effect." 3 

Sec. VII. — Period of Incubation. The period of time which 
elapses between the reception of the etiological poison of yellow 
fever into the system, and the formal access of the disease, seems 
to be generally limited to a few days. Occasionally, however, 
this period is somewhat prolonged. 

Dr. Luzenburg, of New Orleans, states that in the month of 
February, 1844, there were received into the Marine Hospital 
two sailors with yellow fever, who had arrived from the West 
Indies, and who did not fall sick until they touched at the Balize, 
thirteen days after their departure. 4 

1 Cyc. Prac. Med., vol. ii. p. 280. 2 Reports, etc., by Sir J. Fellowes, p. 63. 
3 Burnett on Med. Fever, p. 12. < N. 0. Med. Journ., vol. i. p. 527. 



541 



CHAPTER VII. 

MORTALITY AND PROGNOSIS. 

It must at once be seen, from the preceding history of yellow 
fever, that it is not an easy matter to determine the average rate 
of mortality from the disease. This rate varies very widely in 
different seasons and localities, and with the different forms and 
grades of the disease. In some instances, it is excessive — equal, 
perhaps, to that in the most malignant grade of puerperal fever. 
Dr. Gillkrest quotes Hurtado's Decadas, in which it is stated that 
of the first one hundred and thirty-four cases treated at Murcia, 
in 1804, only three or four recovered; he says, also, that in the 
early part of the epidemic at Gibraltar, in 1828, very few re- 
coveries took place in the Civil Hospital : and that of the first 
thirty-five Jews received into the establishment, all but one were 
swept away. 1 One of the deadliest epidemics on record is that 
of Mobile in 1819. Dr. Lewis informs us that, out of a popula- 
tion not exceeding one thousand, more than one-half of whom 
were acclimated, there were four hundred and thirty deaths ! 
" The mulatto, the black, the Indian, and the white, the native 
and the stranger — were alik'eits victims." 2 Sir J. Fellowes esti- 
mates the population of Cadiz and its suburbs, in 1800, at 57,499. 
Official returns show that the number of persons attacked 
amounted to 48,520, of whom 7,387 died. The population of 
Seville, at the same time, was 80,568, out of which number 76,488 
were attacked with the prevailing fever ; the mortality amounted 
to 14,685 ; more than one-sixth of the entire population. 3 
Of eight hundred and thirty patients with yellow fever, received 
into the General Hospital at Barcelona, in 1821, seven hundred 
and forty-nine died. One thousand seven hundred and sixty- 

1 Cyc. Prac. Med., vol. ii. p. 277. 2 X. O. Med. Journ., vol. i. p. 2S5. 

3 Reports, etc., by Sir J. Fellowes, p. 421. 



542 YELLOW FEVER. 

seven patients were admitted into the Seminario Hospital, of 
wham one thousand two hundred and ninety- three died. 1 

At other times, and under other circumstances, the mortality is 
light. During the passage of the British store-ship Chichester 
from Jamaica to Halifax, in the months of October and Novem- 
ber, 1802, there occurred one hundred and forty-one cases of yel- 
low fever. Of the first seventy-nine, only four recovered; the 
remaining sixty-two all recovered ! This enormous difference 
has been attributed to treatment ; the first series having been 
treated by calomel, and the last by the lancet ; but when it is 
recollected that the ship was sailing north, and had reached the 
35th or 36th degree of latitude when the mortality began to 
abate ; and when it is added, that the weather at this time became 
very stormy, with lightning and rain, we can hardly hesitate in 
referring to these latter circumstances, at least the principal 
agency in the production of the striking change which had taken 
place. 2 There are some facts mentioned by Dr. Lewis, of Mobile, 
showing the differences in the severity of the disease depending 
apparently upon the varying intensity of the poison, or the sus- 
ceptibility of the subjects, or both. The fever of 1819, he says, 
in Mobile, respected no character of persons ; the few whites, 
however, who survived, were acclimated. In the epidemic of 
1837, the old resident, if attacked at all, generally recovered ; in 
1839, most of the citizens were attacked — the long resident very 
mildly, and the stranger severely. In 1842, the disease was any- 
thing but epidemic, and confined to the lower part of the city. 
Every person brought to the hospital this autumn, with yellow 
fever, was unacclimated ; and the same thing was true of cases 
treated in private practice. Those which are called sporadic cases, 
occurring in healthy summers, are confined usually to persons who 
are strangers to the locality." 3 In a private letter from Dr. Lewis, 
dated September 26, 1847, speaking of the epidemic then prevail- 
ing in Mobile, he says it was principally remarkable for its light 
and ephemeral character. He estimates that there had already 
been about five hundred cases; less than forty of which had 
proved fatal; and nearly all of these occurred amongst strangers. 
Most of the cases were amongst the acclimated. 

1 O'Halloran on Yellow Fever, pp. 97, 99. 

2 Annual Register, 1802. a N. 0. Med. Journ., vol. i. p. 417. 



MORTALITY AND PROGNOSIS. 543 

But independent of these differences, depending upon the vary- 
ing grades and character of the disease, there are certain circum- 
stances and conditions, influencing more or less the termination 
of the disease, or indicating this termination. Amongst the 
symptoms which are looked upon as particularly unfavorable, are 
extreme restlessness, deep sighing, hiccough, suppression of 
urine, and especially black vomit. This latter is regarded, by 
general consent, as the precursor and harbinger, almost infallible, 
of death ; and such it most frequently is, but not always. Many 
extensive observers allege that they have never seen a case of 
recovery, after the appearance of this symptom. Louis and 
Trousseau met with no such case at Gibraltar, in 1828. Dr. 
Rush makes a distinction between the true black vomit and the 
matter resembling coffee-grounds ; and he says, that many pa- 
tients who discharged this latter recovered. Dr. Lewis, of Mobile, 
says : " The recoveries after black vomit are exceedingly rare. 
I have ascertained, however, thai fourteen patients were saved in 
1843, after the appearance of this usually fatal symptom, 
long as the vomit is thick and pasty, being raised in small quan- 
tities and thrown up mixed with natural mucus, the physician 
does not despair of his patient. The thin black fluid with the 
coffee-ground sediment is always, in Mobile, a fatal symptom. 
Four of the recoveries took place in the City Hospital, in charge 
of Dr. Ross ; the others were the patients of different medical 
gentlemen in private practice." 1 Louis says, that recovery after 
black vomit occurs much more frequently amongst children than 
amongst adults. 2 Hemorrhage, I believe, is generally regarded as 
an unfavorable indication. Dr. Chisholm says, he never found it 
critical, nor were the local pains ever permanently relieved by it. 
According to Dr. Lewis, hemorrhage from the gums and nose, 
taking place previous to the occurrence of black vomit, is favor- 
able ; and in females, hemorrhage from the uterus did not, in any 
case under his care, terminate fatally. 3 Amongst the signs which 
Arejula considers as mortal, are the dark red or sub-livid color of 
the tongue, like that of a person after drinking red wine, with 

1 N. 0. Med. Journ., vol. ii. p. 300. 

2 Mr. Doughty says lie has seen many hundred cases of black vomit, and never 
knew a patieut to survive where the matters thrown up from the stomach had the 
appearance of coffee-grounds. — Doughty s Observations, p. 14. 

3 N. 0. Med. Journ., vol. i. p. oOO. 



544 YELLOW FEVER. 

saliva sparing in quantity but viscid ; darkness under the eyes ; 
suppression of urine ; and a considerable irritation of the urethra, 
particularly towards the glans, forcing the patient to squeeze the 
penis, as happens to those laboring under a fit of the stone. 1 

Children, females, and negroes, as a general rule, have the dis- 
ease in a milder form, and of course with a smaller mortality, 
than other classes. The mortality at Gibraltar, in 1828, was one 
in four and a half, amongst the men; one in five and a half, 
amongst the women ; and only one in seven, amongst children. 
But the mortality of these classes seems to be subject to variations, 
like those which mark most of the other features of the disease. 
Louis was assured at Gibraltar, by many medical men, who had 
witnessed several epidemics in that city, that the disease was 
sometimes much more severe in children than it was in 1828. 

The danger from this disease is said to be greatest in subjects 
whose habitual residence has been in countries most widely dif- 
ferent in their meteorological features from yellow-fever regions. 
Bally says that, in the Spanish epidemics, natives are less severely 
attacked than the French ; these latter less severely than Germans; 
and Germans less severely than Swedes and Danes. 

The prognostics, as they are called, of the disease, are thus 
summed up by Arejula. I quote from Sir James Fellowes's Re- 
port. " The person attacked with regular chills, a moderate pain 
of the head and loins, nausea and slight vomiting, pulse regular, 
and fever moderate, with a tolerable facility of moving himself, 
and who answered questions put to him as clearly and as distinct- 
ly as usual, most commonly recovered ; and his recovery was 
certain, if, after twenty-four or forty-eight hours, or even before, 
a gentle sweat broke out that lasted thirty hours or upwards, the 
pains subsiding with it, but without the pulse falling, or any of 
the animal or vital functions being apparently disturbed. In 
general, those who were seized with the regular symptoms of the 
disorder, had a great advantage over those in whom the invasion 
came on with irregular or anomalous signs. Those advanced in 
years were not in much danger, and a great proportion of old 
people escaped the disorder. Newly-born infants and very young 
children were not so susceptible of the fever, and they got over 

1 Reports, etc., by Sir J. Fellowes, p. 56. 

2 Du Typhus d'Amerique. Par Vr. Bally, p. 269. 



MORTALITY AND PROGNOSIS. 545 

it when attacked much better, comparatively, than those who 
had arrived at the age of puberty. Those of a white, soft skin, 
and particularly of mild dispositions, escaped much better than 
persons of an opposite description. Females escaped better than 
males, but the fattest were in most danger. Females who were 
brought to bed, or who miscarried during the prevalence of the 
epidemic, were in the greatest danger. It was observed, gene- 
rally, that this fever exercised all its fury upon those who had 
reached the age of puberty, and upon the strongest adults, those 
especially of a dark color ; and upon those most covered with 
hair. It was most frequently fatal to the pusillanimous, or to 
very timid persons. Ailing or sickly persons, and such as had 
suffered from lues, or those who had indulged much in venery, 
almost invariably died. The patients who began to sweat co- 
piously a few hours after being taken ill, with an increased un- 
easiness at the pit of the stomach, attended with great restlessness 
and malaise, most commonly died. The black vomit which came 
on after the third or fourth day of the fever, was a bad sign, and 
it carried off numbers of the sick ; however, a great many escaped 
with this symptom, and were soon after perfectly recovered. The 
earlier in the fever the black vomit appeared, the worse was the 
sign ; but in order to judge with accuracy, it was necessary to 
pay attention to the state of the pulse, and to the strength of the 
patient. When the black vomit was more copious each time the 
patient threw it up, it was regularly a fatal sign ; but if it could 
be stopped, there were hopes of recovery. When blood oozed 
from the gums, without issuing from any other part of the, body, 
it was considered favorable, particularly if this discharge was 
observed after the fifth or sixth day. The change of color of the 
sick to a leaden hue was constantly mortal. A suppression or 
defective secretion of urine was a very frequent and fatal sign. 
All those who positively refused to take medicine or nourishment 
died. It was easy to prognosticate the death of those sick who 
could not be made to lie in bed in the usual way, but who lay 
across it. When persons of modesty were insensible to shame, 
or indifferent about the exposure of their persons, death invariably 
followed." 

Dr. Biseuno, in an interesting letter to Dr. Burnett, containing 
some account of the yellow fever of Carthagena, during the years 
1804, 1810, 1811, and 1812, says : " The disease preys without 
35 



546 YELLOW FEVER. 

mercy on the young and robust, to whom it proves highly fatal, 
as well as to pregnant women, whom it causes to miscarry, doubt- 
less with a view to make up for the lenity with which it affects 
the fair sex in general." 1 Bally says those with a vigorous con- 
stitution suffer more than the feeble and delicate ; but that this 
rule is not without qualification — that violent epidemics, like that 
which prevailed amongst the French soldiers, at St. Domingo, in 
1802, and 1803, seize upon all alike, with very little distinction. 2 
He adds that, in the torrid zone, death may be predicted with 
certainty in a person who is seized with the disease amidst the 
lassitude occasioned by coition; and that in Spain the mortality 
amongst the newly married, and libertines, is greater than 
amongst others. 

i Burnett, p. 242. 

2 Du Typhus d'Amerique. Par Vr. Bally, p. 270. 



547 



CHAPTER VIII. 

DIAGNOSIS. 

A STRONGLY-marked case of fatal or grave yellow fever can 
hardly be confounded with any other disease. An initiatory chill 
of moderate duration and severity, immediately followed by in- 
tense pain in the head, back, and limbs ; redness and suffusion 
of the eyes; moderate excitement of the circulation ; moderate heat 
of the surface ; loss of appetite ; thirst ; and a white tongue, with red 
tip and edges ; these febrile symptoms, marking the first stage of 
the disease, continuing for one day or so, and then associated with, 
or followed by, epigastric pain and distress; nausea and vomiting; 
restlessness and anxiety, often more or less paroxysmal ; and in 
from three to five or six days after the attack, by yellowness of 
the eyes and skin ; vomiting of a matter resembling coffee-grounds 
held in a dark-colored fluid ; very dark or black stools; coldness 
of the extremities ; increasing and excessive restlessness, with 
occasional hiccough ; hemorrhages from different parts of the 
body, and suppression of urine — the mind in many instances 
remaining clear to the end, and death taking place in from five 
to seven or eight days from the attack ; — these phenomena, thus 
combined and thus following each other, constitute a disease 
which it seems impossible to mistake for any other. Asiatic cho- 
lera, puerperal peritonitis, and distinct smallpox are not more 
clearly and broadly marked, by their peculiar and characteristic 
physiognomy, than the yellow fever, occurring in this form; and 
had we not abundant evidence of the extent to which even clear 
heads and sound judgments may be mystified and perverted by 
hypothetical and a priori systems of medical philosophy, it would 
seem incredible that this disease should have been regarded by 
many observers as a variety merely of ordinary remittent fever. 
A single remark should be made in relation to the state of the 
organs after death, as an element in the diagnosis of fatal cases. 
The only phenomena peculiar to the disease are the change in the 



548 YELLOW FEVER. 

color of the liver, and the presence of the matter of black vomit 
in the stomach and intestines. In cases where either or both of 
these are found, we have an additional and very conclusive evi- 
dence of the nature of the disease. It is very important, how- 
ever, to add, that the absence of both these conditions is not to 
be taken as positive proof of the non-existence of the disease, 
in any given case, since it is quite certain that, in a considerable 
number of instances, death takes place without any formation of 
the matter of black vomit ; and there is also good reason to be- 
lieve that the change in the color of the liver is not a constant 
occurrence. 

The diagnosis of the more moderate grades of the disease, in- 
cluding even the severer forms which terminate in recovery, may 
be somewhat less positive, perhaps, than that of the foregoing 
cases; but it cannot often be attended with any difficulty or 
doubt. It is very true, that some of the most striking features of 
the disease are often or usually wanting in these cases ; there is 
frequently no yellowness of the skin, but slight restlessness, and 
epigastric distress, or none ; and no black vomit ; but the violence 
of the local pains, the early suffusion of the eyes, and the rapidity 
with which the disease passes from the second stage to convales- 
cence and recovery, will be quite sufficient to supply their places, 
and to remove all uncertainty. 

The diagnosis of the milder and slighter form of yellow fever 
must often be more or less qualified and doubtful ; and it will de- 
pend in part upon the circumstances under which the disease 
occurs. Thus, if a considerable number of persons in the same 
family or neighborhood are attacked, during the prevalence of 
yellow fever, with pains in the head, back, and limbs, moderate 
febrile excitement and redness of the eyes — especially if these 
persons are mostly children, negroes, or individuals more or less 
acclimated, there can be but little doubt, if any, in regard to the 
character of the disease. Mr. Pym says : " The most character- 
istic symptom of the disease is the peculiar pain in the forehead 
and eyeballs, with the drunken appearance of the eye" 1 

Again, the diagnosis may sometimes be rendered somewhat 
doubtful, by the presence of the remittent or periodical element 
in the disease. Dr. Lewis, of Mobile, has called the attention of 

1 Burnett, p. 209. 



DIAGNOSIS. 519 

physicians particularly to these mixed cases, and to the difficulty 
which often attends their diagnosis. It does not appear, however, 
that the peculiar features of yellow fever are much modified, or 
the usual course of the disease much interfered with, by the ad- 
dition of this periodical or remittent character. Dr. Lewis, in his 
description of the Mobile epidemic of 1843, says : " Some phy- 
sicians complained that they were always taken by surprise in 
these cases ; that there was no symptom which could lead them 
to suppose that they were cases of yellow fever ; hence they 
viewed them as simple intermittent, running, under atmospheric 
influence, into black vomit. I was deceived in three cases only ; 
two of which were under my treatment, and the other I saw by 
accident. After this, I was able to make a proper diagnosis, 
usually on the second or third day. During the apyrexia, there 
were the peculiar pulse and uneasiness belonging to the calm or 
passive stage of yellow fever ; and in the absence of these, the 
eye or skin was sometimes indicative of the character of the dis- 
ease." 1 

Finally, cases will unquestionably now and then occur, so in- 
distinctly and obscurely marked, or so mixed up with other mor- 
bid phenomena — so anomalous and irregular in their symptomato- 
logical manifestations — as to escape the scrutiny of the closest 
and most experienced watcher. What is true of most other dis- 
eases is true also of this ; and here as elsewhere in the domain 
of diagnosis, although as a general rule, and in an immense ma- 
jority of cases, our conclusions may be absolute and positive, we 
are sometimes held to the necessity of being satisfied with such as 
are only qualified and approximative. 

1 N. 0. Med. Journ., vol. i. p. 292, 



550 



CHAPTER IX. 

THEORY. 

The theory of yellow fever, like that of the preceding diseases, 
can consist, at present, only of a few probable approximations. 
We may pretty safely say, in the first place, that it is not a sim- 
ple gastritis. Notwithstanding the general presence and the 
grave character of the lesions of the gastric mucous surface in 
fatal cases, and the corresponding constancy and gravity of the 
gastric symptoms, it seems to me that a rational interpretation 
of all the phenomena of the disease leads inevitably to the conclu- 
sion above stated. The order of succession, in the phenomena 
of yellow fever, is not such as occurs in simple acute gastritis. 
The gastric symptoms do not accompany the general febrile ex- 
citement ; the latter precedes the former. If the high fever of the 
first period is dependent upon gastritis, there should be at the 
same time some local symptoms of this latter. The first stage 
of the disease is not accompanied by any signs of gastric inflam- 
mation ; and in mild cases, and not unfrequently also even in 
pretty severe cases which terminate in recovery, there are no 
such signs during any period of the disease. This could not be 
so generally the case, if the disease consists primarily and essen- 
tially in an inflammation of the mucous membrane of the stomach. 
The gastritis, there is every reason to believe, is a secondary lesion 
like that of Peyer's glands in typhoid fever, one of the results, 
immediate or remote, of the unknown poison of the disease. 
This interpretation is in no way inconsistent with the importance 
which I am disposed to attach to the local disease. This is proba- 
bly one of the principal causes of danger and death. 

Of the peculiar lesion of the liver, I have already sufficiently 
spoken. We know too little of its nature and relations, to justify 
us in attempting to estimate its importance, or to fix its position, 
in the theory of the disease to which it belongs. ' 

It is very probable that a most important element in the patho- 



THEORY. 551 

logy of yellow fever is to be found in the alteration of the blood 
which has already been described. The etiological poison of the 
disease, received into the system, works a morbid change of some 
sort in this fluid, the immediate effects of which are manifested 
in the first stage of the disease ; in mild and moderate cases, 
these effects are carried no further ; but in grave and fatal cases 
there are superadded to the contamination of the blood, certain 
consecutive local lesions, especially of the liver, and the mucous 
membrane of the stomach. 



552 



CHAPTER X. 

TREATMENT. 

Sec. I — Preliminary. The treatment of yellow fever is not yet 
settled. The conflicting opinions, which we have so often en- 
countered in the course of our previous investigations, again meet 
us here. I do not mean to say that there are not now, or that 
there have not always been individual practitioners, thoroughly 
believing and confidently proclaiming that they themselves had 
ascertained the best and most effectual means of combating and 
controlling this disease — of diminishing its severity, and prevent- 
ing its fatal issue. There are now, and there always have been, 
multitudes of such. It is, indeed, a very remarkable fact that in 
no department of practical medicine have loftier pretensions been 
made than in this; nowhere else has there been claimed a more 
entire and absolute control over disease than here. Medical 
skill has plumed itself upon its most brilliant successes ; medical 
art has proclaimed its most wonderful power, in the treatment 
of yellow fever. Dr. Rush said that, during the great Philadel- 
phia epidemic of 1793, at no time did he fairly lose more than 
one in twenty of his patients ; and a like siren accompaniment 
runs through the long and stormy annals of the disease. But still, 
yellow fever has lost none of its ancient terrors; the blow with 
which it strikes down its victim, to-day, in New Orleans, is as 
unerring and resistless as it was half a century ago at Cadiz or 
Gibraltar. Neither is there any general agreement amongst medi- 
cal men in regard to the most effectual means for controlling the 
disease ; one method is recommended by one observer, another 
by a second, and another by a third. These are the grounds for 
the statement with which I have commenced this chapter — that 
the treatment of yellow fever is not yet settled. 

Under such circumstances, the duties of a conscientious his- 
torian of the disease, although they may be difficult, are suffi- 
ciently plain. He is not to dogmatize ; and he is to be especially 



TREATMENT. — MERCURIALS. 553 

careful not to espouse opinions of an exclusive, partisan, and 
doubtful character. His functions are those of the judge, and not 
those of the advocate ; he is carefully to examine and analyze the 
evidence before him, and honestly to estimate its value, and then, 
as nearly and as fully as his means and ability will enable him, 
he is to state the case as it is — clearly and fairly, without preju- 
dice and without passion. 

In the further prosecution of this subject, I shall first speak of 
the three remedies which have attracted most attention, and which 
have been most extensively used — I mean, mere urials ; bleeding; 
and tonics, or stimulants ; and I shall then mention some other 
methods of treatment that have been adopted by certain practi- 
tioners. 

Sec. II. — Mercurials. By the mercurial treatment of yellow 
fever, I mean the use of mercury for the purpose of producing its 
specific effects on the system, as indicated by the presence of 
salivation. This practice constituted the favorite method of many 
British, and of some few American, physicians ; and it has been 
long and very extensively applied. One of its earliest and most 
zealous champions was Dr. Chisholm. He placed his sole reli- 
ance upon it for the cure of the disease. His usual mode of ad- 
ministering it was to give ten grains of calomel, either alone, or 
in combination with jalap, at the beginning of the disease, and 
then to repeat the calomel, either alone, or in combination with 
opium, every three hours, until the salivary glands became 
affected ; which generally happened, he says, in less than twenty- 
four hours from the commencement of the treatment. Dr. Chis- 
holm speaks of this treatment as new; says that he resorted to it, 
not on the authority of others, but led by his own reflections on 
the nature of the disease, and by the inefficacy of the means 
which he had already made use of; and he always speaks of his 
success as astonishing as it was gratifying. 1 Dr. Gillkrest enu- 

1 In a subsequent part of his work, Dr. Chisholm j\istifies his free use of mer- 
cury, by showing that the practice was not new in the treatment of the West India 
yellow fever; but that it had been extensively adopted near the middle of the then 
century. Dr. Bancroft quotes Dr. Henry Warren, as saying, in 1740. after alluding 
to what lie calls a very odd and unwarrantable practice which had prevailed for 
many years among several of the plantation practitioners of Barbadoes, of giving 
calomel in inflammatory fevers, that he had never yet heard of mercury being given 
in this malady, and hoped he never should hear of it. — Bancrofts Essay, p. 77. 



554 YELLOW FEVER. 

merates a great number of British practitioners who still rely upon 
this method; and he gives to it the sanction of his own experience. 
Amongst American physicians of the present day, who adopt a 
similar practice, the most distinguished is Professor Dickson, late 
of the New York University, and now of Charleston, S. C. Dr. 
Dickson has been long familiar with yellow fever, and he gives 
his most emphatic and unqualified testimony to the excellence 
and superiority of this method. Still, it can hardly be denied, 
that the balance, of authority is on the other side of this question. 
Nearly all the French and Spanish, most of the American," and 
many of the British physicians, now doubt the value of this mode 
of treatment ; or they are decidedly opposed to it. Dr. Burnett 
says : " I have heard of the utility attending the exhibition of 
mercury in this disease ; but I can with truth affirm that, employed 
in any other shape than as a purgative, I have never seen it in 
the early stage attended with the smallest advantage." He 
sailed, he says, for Jamaica, in 1802, strongly prepossessed in 
favor of mercury, but a service of nearly a year and a half on that 
station served to convince him that he had greatly overrated its 
virtues. Without particular reference to the many patients who 
perished around him, in the ships, and the hospitals, four of his 
most intimate friends died under the use of mercury, one of them 
fully salivated. In protracted cases, with signs of cerebral dis- 
ease, he thinks it of great service, in small doses. 

Mr. Doughty says : "In our hospital, which I have stated was 
soon crowded, and with cases of the most aggravated nature, the 
mercurial plan of treatment was for a time tried, but with no 
success, as in seven cases out of ten the mouth could not be 
affected; where the mercurial action did manifest itself, the pa- 
tient was considered safe; but this effect was so uncertain, that I 
shall never be led to adopt it again, as a general plan, should 
any circumstance induce me to revisit the West Indies." 

Sir James Fellowes, in a notice of the epidemic at Cadiz in 
1813, says : " Mr. Short, the surgeon of the German battalion, 
informed me, that five soldiers were taken ill whilst under a state 
of ptyalism, from the use of mercury. They all recovered. Mer- 
cury, in the hands of Staff-Surgeon Vance, proved to be of no 
use, except as a purgative in the beginning of the disease." 1 

1 Reports, etc., by Sir J. Fellowes, p. 300. 



TREATMENT. — ANTIPHLOGISTIC METHOD. 555 

Dr. Bancroft says: "I cannot, with an eminent and respecta- 
ble physician, Dr. Grant, who treats of this practice, aver, that 
although I have been called in to attend many under such cir- 
cumstances, not one survived, and that they became more victims 
to the mercury than even to the fever; but I can aver, that I had 
not a few opportunities of observing the effects of mercury given 
in this disease, while I served, in 1796 and 171*7, as physician 
to the army, under Sir Ralph Abercrombic, in the West Indies, 
and that I saw nothing, which, to my understanding, could afford 
a proper encouragement to continue the mercurial practice: and 
therefore though I have adopted no invincible, nor as I hope 
unreasonable prejudice on the subject, I cannot venture to re- 
commend the use of mercury to excite salivation in yellow fever, 
without further evidence of its utility." 1 Louis says there was 
no reason to think that the mercurial practice was of any utility 
in the yellow fever of 1828, at Gibraltar. 

Sec. III. — Antiphlogistic Method. Early and free general 
bloodletting, with or without the local abstraction of blood from 
the head, or epigastrium, or both, has constituted a common and 
favorite mode of treatment with many practitioners. Our distin- 
guished countryman, Dr. Rush, it is well known, was one of the 
staunchest champions of the lancet in yellow fever. lie stood by 
it, through evil and through good report, with a tenacity and deter- 
mination characteristic of the polemics of our profession. In his 
account of the fever of 1704, in Philadelphia, he gives a tabular 
statement of his bleedings, in twenty-three cases. The number 
of bleedings, in each case, varied from three to fifteen ; in more 
than half the cases, he bled nine times, or more ! The quantity 
of blood taken from each patient varied from fifty to one hundred 
and fifty ounces — the average quantity being ninety-three and a 
half ounces ! 2 In 1797, Dr. Dewees is said to have bled Dr. 
Physick, in yellow fever, to the extent of one hundred and seventy- 
six ounces. 3 One of the boldest bleeders was Dr. Robert Jack- 
son, the Englishman, in his practice in the West Indies. His 
common quantity was from three to six pints, taken suddenly, and 
at once. His treatment was founded on a j^'iori notions, and has 
nothing but general assertions to justify it. Dr. William Burnett, 

1 Bancroft's Essay, p. 85. 2 Med. Inq., vol. iii. p. 221. 3 Ibid., vol. iv. p. 22. 



556 YELLOW FEVER. 

who was at the head of the Medical Department of the British 
Navy in the Mediterranean, from 1810 to 1818, regarded yellow 
fever in its early stages as purely inflammatory. The disease, he 
says, is then simple in its nature, and easily to be managed ; and 
the fate of the patient is in the hands of the physician. He relied 
principally on bloodletting, general and local. He says that 
although syncope is often occasioned by the loss of a few ounces 
of blood, the bleeding should be repeated, if it is not specially 
contraindicated — the patient being placed in a horizontal posi- 
tion. He lays great stress on the value of bleeding from the tem- 
poral artery; he says the headache is greatly ameliorated, if not 
entirely removed, by this operation, and that in many instances 
the patients feel the pain escaping with the blood.~ In one case, 
he bled from the temporal artery to the amount of ninety ounces. 
In many instances, he bled to the amount of one hundred and 
thirty, one hundred and forty, and even two hundred ounces. 1 

An interesting, and as far as it goes a very conclusive trial of 
the comparative merits of the antiphlogistic and mercurial methods 
of treatment, was made during the years 1828, 1829, and 1830, 
on board some of the United States vessels, in the neighborhood 
of the West Indies, and in the hospital at Pensacola. On board 
the Hornet, there were fifty-five cases, and eight deaths. The first 
twenty-six were treated on the mercurial plan ; and five of them 
were fatal : the remaining twenty-nine were treated on a differ- 
ent plan; and three of them were fatal. Of the few who were 
bled, every one recovered. In the Grampus, there were thirty-six 
cases and four deaths. The treatment, generally, was pretty 
actively antiphlogistic. There was no death after venesection. 
From the Peacock, there were sent to the hospital, at Pensacola, 
thirty-eight patients, nine of whom died. The treatment in the 
hospital was mercurial ; but on board ship it was antiphlogistic. 
Of the nine fatal cases, eight were treated with mercury, of whom 
five were salivated, or had the mouth affected. The average du- 
ration of the disease, including convalescence, was about one week 
greater in those treated by the mercurial than in those treated by 
the non-mercurial method. 

I could add largely to these testimonials in favor of the value 
of bloodletting. It is true, nevertheless, that the practice is very 

1 Burnett on Med. Fever, p. 19. 2 Amer. Journ. Med. Soi., Aug. 1833. 



TREATMENT. — ANTIPHLOGISTIC METHOD. 567 

far from being generally adopted, and it has always encountered 
very strong and decided opposition. This bold depleting prac- 
tice has failed to commend itself to the general favor of the pro- 
fession; we may go further than this, and say that it is generally 
rejected as improper and unsafe. Dr. Chisholm says that, in 
young and robust subjects, newly arrived, and with strongly- 
marked inflammatory symptoms, one plentiful bleeding may be 
of infinite service ; but, as a general practice, he condemns it in 
the strongest and most unqualified terms. Not a single case, 
he says, in which bleeding has been employed as a principal 
remedy, has terminated favorably. Sir James Fellowes says : 
" As far as my information extends, the practice of bleeding has 
been of late entirely laid aside in Spain in the treatment of this 
fever ; and although I have seen some patients recover in the few 
instances in which it had been followed, it did not appear to be 
necessary or proper." 1 Sir Gilbert Blanc says: "With regard 
to bloodletting, the most that can be said in its favor is, that, if 
there should be a hard, throbbing pulse, with violent pain in the 
head and back, it is safe, in the first twelve hours. It is, however, 
in all cases extremely dangerous, except in the circumstances just 
mentioned." 2 The leading practitioners of Mobile reject it almost 
entirely. Dr. Dickson does the same. 

As a means of reducing the active excitement of the first stage, 
and as a substitute, in some degree, for bloodletting, the cold 
affusion has been made use of. Dr. Dickson praises it very highly. 
"Relief from the pungent heat of the skin," he says, "the tor- 
menting thirst, the distressing headache, the pain and irritability 
of stomach, you will never fail to procure. This relief, it is true, 
will be partial and transient, but the remedy may be repeated as 
often as seems requisite, without danger or injury. The termina- 
tion of the chill, if there be one, when the face becomes flushed, 
and the surface dry and hot, a condition almost characteristic in 
the degree attending this form of fever, is the moment for affusion. 
Seat your patient in a convenient vessel, and pour rapidly from 
some slight elevation, upon his head and shoulders, and over his 
naked body, a full large stream of cold water, continuing it until 
his face becomes pale, or his pulse sinks. In general, the sick 
man himself will exult in the delightful ease which follows it, and 

1 Reports, etc., by Sir J. Fellowes, p. 407. * Obs. Dis. Seamen, p. 414. 



558 YELLOW FEVER. 

will solicit its frequent repetition. I have never yet seen any un- 
pleasant consequences from it. Even children and timid women 
reconcile themselves readily to the shock of the affusion, and re- 
gard it as pleasurable rather than otherwise. The surface should 
be rubbed dry, and the patient, on lying down, covered so as to 
be comfortably warm." 1 

Sec. IV. — Cinchona ; Tonics and Stimulants. There have 
always been a certain number of practitioners who have pursued 
a decidedly tonic and stimulating course in the management of 
yellow fever, even from the commencement of the disease. Dr. 
Lafuente, a Spaniard, was in the habit of giving six or eight 
ounces of Peruvian bark during the first forty-eight hours of the 
disease ; and this practice, with certain modifications, still finds 
some advocates and disciples. I do not think there is any satis- 
factory evidence of its efficacy ; although it is very possible that 
it may be useful in those cases of the disease which are compli- 
cated with the pathological element of periodicity. I am not now 
speaking of the use of cordials and stimulants during the second 
and third stages of the disease. These remedies are very gene- 
rally resorted to at this period. 

Sec. Y. — Purgatives. There is a pretty uniform agreement 
amongst practitioners in regard to the propriety and advantages 
of an early and efficient cathartic in the treatment of yellow fever. 
Different articles are used by different physicians ; as a general 
rule, Spanish and French practitioners preferring the milder and 
blander laxatives, while British and American physicians usually 
resort to calomel in combination with or followed by some other 
purgative. Dr. Rush's famous powders of calomel and jalap, are 
well known. Dr. Dickson promotes the action of the calomel by 
the use of Epsom salts. 

Sec. VI. — Spanish Method. Yellow fever prevails nowhere 
more extensively than along the Mediterranean coasts of Spain, 
and it can hardly fail to be of some interest to my readers to know 
the plan of treatment generally adopted by the Spanish physi- 
cians. This plan, with the exception of the ultra bark treatment 

1 Dickson's Essays, &c, vol. i. p. 360. 



TREATMENT. — MOBILE METHOD. 559 

of Fuente, is pretty uniform ; and consists principally in the use 
of mild and cooling laxatives, such as supertartrate of potass and 
tamarind water, with subacid drinks, in the early stages of the 
disease, and cinchona in the latter period. There is a general 
aversion, amongst the Spanish practitioners, to the lancet and 
mercury. Dr. Flores, at Cadiz, in 1813, at his first visit, which 
was usually in the evening or night, ordered an injection of sweet 
oil, warm aromatic drinks, and sinapisms to the feet. The next 
morning, he gave ten grains each of calomel and jalap, with bar- 
ley water, or light broth, promoting their action, if necessary, by 
enemata. If vomiting was present, the calomel was given in 
divided doses, in pills, and continued till it operated on the bow- 
els. Its free action was generally followed by relief — general 
tranquillity, mitigation of local pains, and perspiration. On the 
approach of the third stage, tincture of cinchona, animal broths, 
sago and wine, were resorted to. If there were threatenings of 
black vomit, a vinegar and mustard poultice was applied to the 
epigastrium, saline injections were administered, and sweet spirits 
of nitre and opium were added to the bark and cordials. The 
practice of Sir James Fellowes was much the same. 

Sec. VII.— Mobile Method. According to Dr. P. II. Lewis, 
the physicians of Mobile have, with great unanimity, adopted a 
method of treatment corresponding pretty nearly to the foregoing. 
He speaks especially of the severe and malignant forms of the 
disease — milder cases generally recovering under various and 
even opposite systems of management. In the early stage, they 
give a dose of calomel, followed by castor or olive oil, or salts 
and senna, so as to act freely upon the bowels. If the rigors 
continue long, a warm mustard-bath is ordered. Perspiration is 
promoted by warm drinks ; and cups are applied to the cervical 
or epigastric region, as they seem to be indicated. In the second 
or stage of calm, no active system of practice is pursued. The 
lighter diffusible stimulants and diaphoretics are usually given, 
with blue pill. The transition of the disease from the second to 
the third stage is carefully watched, and met with an active stimu- 
lating treatment. Brandy toddy or julep is usually preferred. 
It is cautiously given, until it is ascertained that the patient 
has a relish for it ; after which it is pressed until the depressing 
tendency of the disease is fully arrested. After the restlessness 



560 YELLOW FEVER. 

has moderated, and the pulse rallied, the stimuli are continued in 
such quantities as are necessary to sustain the patient. After the 
liberal use of brandy, small quantities of chicken or oyster broth 
are cautiously given; if this should also be retained by .the sto- 
mach, the fears of the approach of black vomit, which were pre- 
viously entertained, begin to fade away. General bleeding, in 
this class of cases, is considered improper and hurtful. It is re- 
sorted to only in the febrile stage of the open inflammatory form 
of the disease, and is even then used cautiously. But small re- 
liance is placed upon quinine. " No physician in Mobile, who 
has any experience, expects to cut short a grave and serious case 
of yellow fever." My readers can hardly fail to be struck with 
the almost exact similarity between the Spanish and the Mobile 
methods of treatment. 

Dr. Nott of Mobile has for several years been in the habit of 
administering creosote during the febrile stage. After opening 
the bowels, he puts twenty drops of creosote to six ounces of 
spirit of Mindererus, with alcohol enough to dissolve the creosote ; 
and then gives half an ounce every two hours. Dr. Lewis says 
of this remedy: "It is certainly the most efficacious means for 
arresting the disposition to vomit and retch that I have yet found." 

Sec. VIII. — Prophylactics. There can be no doubt, I sup- 
pose, that the most effectual means of warding off the disease 
from those who have been exposed to its essential cause, are to 
be found in cleanliness, temperance, and cheerfulness. The two 
former conditions it is not difficult to comply with ; but according 
to what code of metaphysics or philosophy, the solemn warnings 
to men, standing in the very shadow of the wings of the angel of 
pestilence, to be of good heart, and not afraid — and this too at 
the peril of their lives — are expected to be heeded, is more than I 
am able to understand. In connection with the prevention of the 
disease on shipboard, Dr. Barrington says: "The chloride of 
lime is an important agent in purifying places inaccessible by the 
scrubbing-brush and holy-stone, and destroying the noxious efflu- 
via of crowded apartments. That it is highly useful on ship- 
board has been sufficiently demonstrated. It is now in general 
use in the West India squadron. In the late cruise of the Erie, 
this article was dealt out unsparingly, and occasionally to the 
temporary annoyance of those on board; and I am convinced that 



TREATMENT. — CONCLUSION. 561 

to this, with the prompt and effective co-operation of the executive 
officer, in having every tangible part kept free from filth, may be 
chiefly attributed that ship's escape from the most alarming dis- 
ease of the tropics. The chloride mixed with water was poured 
into the pump-wells, and distributed throughout the holds, chain- 
lockers, berth-deck, and other parts." "Music," continues the 
same sensible writer, "though not often regarded as a preventive, 
is in my opinion an important mean of placing the system, through 
the influence of the common sensorium, in a favorable condition 
to resist the action of the morbific causes. Smoking tobacco 
must also be enumerated amongst the means of keeping off attacks 
of fever in what are called miasmatic situations. In an infected 
atmosphere, particularly at night, I have seen and experienced 
sufficient not to doubt its utility." 1 

Sec. IX. — Conclusion. I shall finish this chapter with the 
following conclusions, which we are justified, I think, in adopting. 

The simple and milder form of yellow fever, occurring some- 
times in unacclimated adults, but more frequently amongst the 
acclimated or partially acclimated, and in children, usually termi- 
nates favorably, independent of any of the ordinary modes of 
treatment. Perhaps this termination is promoted by a mild but 
efficient cathartic. 

The open inflammatory form of the disease is mitigated in se- 
verity, and its danger diminished, by prompt and pretty free 
bloodletting — general and local ; and by an efficient cathartic. 

The congestive form of the disease, and the other forms, if they 
pass into the stage of collapse, usually terminate fatally, and are 
but little under the control of art. In these cases, the method of 
treatment usually folloived by Spanish practitioners, and adopted 
by the physicians of Mobile, seems to proynise more success than 
any other. 

Finally, and lest some of my friends may think me over cau- 
tious in my conclusions, I shall add to what I have said the seal 
of hoary wisdom, and the sanction of ripe knowledge. Lempriere 
says: "I am very apprehensive, from experience, that both 
parties have been too sanguine in their practice, and that many 
of the successful cases have been confounded with the common 

1 Amer. Journ. Med. Sci., Aug. 1833. 

36 



562 YELLOW FEVER. 

remittent; and that as yet we have not ascertained what is the 
most judicious mode of treating the disease ; and I am likewise 
convinced that there are many cases which from the first attack 
are fatal, and which from their nature totally exclude the chance 
of recovery by medicine." 1 

Let us listen to the great Sir Gilbert Blane. He says: " I feel 
this as the most painful and discouraging part of this work, the 
yellow fever being one of the most fatal diseases to which the 
human body is subject, and in which human art is the most un- 
availing. 

" It seems hardly to admit of a doubt that there are particular 
instances of disease in their own nature determinedly fatal ; that 
is, in which the animal functions are from the beginning so de- 
ranged, that there are no possible means in nature capable of 
controlling that series of morbid motions which lead to dissolu- 
tion. Of this kind appear to be the greatest number of cases of 
the plague, many of the malignant smallpox, and some of fevers,, 
particularly of that kind now under consideration." 2 

1 Obs. Dis. Army. Lempriere, vol. ii. p. 92. 3 Obs. Dis. Seamen, p. 411. 



563 



CHAPTER XI. 

DEFINITION. 

Yellow Fever is an acute affection ; occurring at all ages, but 
much more frequently during the middle and active period of 
life, than either earlier or later ; attacking, in a large majority 
of instances, persons who are not permanent residents in the 
places where it prevails — sometimes extending, however, espe- 
cially in localities where it is of rare occurrence, to such residents ; 
rarely occurring twice in the same person ; much more common 
in the white than the negro race; generally milder in its character 
amongst children and women than amongst men; confined to 
certain geographical localities, and especially to commercial sea- 
ports in hot climates; prevailing most extensively during the 
latter part of the hot season ; often epidemic, but sometimes 
sporadic in its appearance ; not capable of transmission from one 
person to another in a pure atmosphere ; depending, for its 
essential cause, upon a poison, of terrestrial origin, the nature and 
composition of which are entirely unknown — which poison may 
be shut up in small and close apartments, in clothes, bedding, 
and so on, and transported from one place to another, and which 
is destroyed by a freezing temperature : sudden in its access ; 
commencing with an initiatory chill, ordinarily of moderate se- 
verity, and of short duration; the latter accompanied with acute 
and violent pains in the head, back, and limbs, or immediately 
followed by them ; then by a red suffusion of the eyes, moderate 
heat of the skin, and moderate acceleration of the pulse, loss of 
appetite, and thirst ; a moist, white, villous tongue, with rosy tip 
and edges ; — these febrile phenomena diminishing in activity, 
and mostly disappearing, in from twenty to thirty-six hours ; — 
the first stage of the disease, thus characterized, passing, in mild 
cases, into convalescence, but in grave cases being followed, after 
an interval of apparent but deceptive amelioration, by nausea 
and vomiting — the matter ejected from the stomach, in cases 



564 YELLOW FEVER. 

that are to terminate fatally, resembling coffee-grounds ; black or 
dark-colored stools; epigastric distress, general restlessness, and 
jactitation; sighing respiration; hiccough; a yellow color of the 
skin ; coldness of the extremities gradually extending .to the 
trunk ; and, finally, by death ; — the mind usually remaining free, 
but apathetic and indifferent, up to the close of life ; which symp- 
toms differ very widely in their degree of severity, and especially 
in their number and combination, in different cases, thus giving 
rise to different varieties and grades of the disease ; which symp- 
toms, furthermore, may either subside and disappear, in the 
course of a few days from the time of their commencement, or 
may terminate with death, between the third and seventh day of 
the disease ; the bodies of patients exhibiting, on examination 
after death, in most cases, a yellow or buff color of the liver, 
with dryness of its tissue ; black spots or masses, more or less 
numerous, in the lungs ; softness and flabbiness of the substance 
of the heart ; and in nearly all cases, unusual thinness and 
fluidity of the blood ; and redness, mamellonation, changes in the 
thickness, and softening — one or more — of the mucous membrane 
of the stomach ; this organ and the intestines usually containing 
a considerable quantity of a very dark or black fluid or semi- 
fluid matter ; which disease differs essentially from all others, 
in its causes, its symptoms, and its lesions ; and is only to a 
moderate extent, at least in its graver forms, under the control 
of art. 



565 



CHAPTER XII. 

BIBLIOGRAPHY. 

My readers will not expect me to attempt to embrace in a 
short supplementary chapter, like this, the almost boundless 
domain of the literature of yellow fever. I shall content myself 
with doing here what I have done in the corresponding portions 
of the preceding parts of my book ; — I shall enumerate merely 
some few of the publications upon yellow fever, confining myself 
mostly to those of original pretensions, and from which the mate- 
rials for the foregoing history have been mainly derived. It is 
proper that I should here express my acknowledgments to Dr. 
La Roche, for the free use which he has given me of his very ele- 
gant and complete library of this disease. 

Observations on the Diseases incident to Seamen. By Gilbert 
Blanc, M. D., F. R. &, etc. London, 1T85. Sir Gilbert Blane 
was surgeon to the great British fleet, under Admiral Rodney 
and Lord Hood, during the French, Spanish, and American war. 
from 1T71> to 1783. The fleet consisted of from twenty to forty 
ships of the line — the whole force sometimes amounting to more 
than twenty thousand men. The principal theatre of its opera- 
tions was the neighborhood of the "West India Islands, although 
portions of the fleet were occasionally passing to and fro, between 
the Islands, and North America and Great Britain. Sir Gilbert 
Blane's volume, of five hundred pages, is mostly made up of a 
medical history of the fleet, and of separate treatises on what he 
calls " the three sea epidemics' — -fever, scurvy, and dysentery. 
This work, like all the writings of Blane, is marked throughout 
by sound common sense, accurate observation, clear-headed saga- 
city, and the most thoroughly positive and correct medical phi- 
losophy. It is deplorable that this philosophy is so rarely found 
in the works of his countrymen. Some notion of the extent of 
Blane's experience, as well as of the terrible destructiveness of 
the service to which he was attached, may be gained from the 



566 YELLOW FEVER. 

statement that, in the period of three years and three months, the 
number of deaths, in the fleet and hospitals, amounted to four 
thousand three hundred and forty- eight ; of this number, three 
thousand and two hundred perished from disease. Upwards of 
three thousand were also lost at sea, in the hurricane of October, 
1780, and in the storm of September, 1782. The descriptions of 
yellow fever, and of bilious remittent fever, are short, but clearly, 
accurately, and excellently written ; and many of his observa- 
tions have been incorporated into my book. 

Dr. William Hillary's Observations on the Weather and the 
Diseases of the Island of Barbadoes is a most excellent and 
sensible book. His description of yellow fever is wonderfully 
graphic and true. He thought the disease was not contagious, 
except, perhaps, in some rare cases. His treatment consisted in 
early moderate bleeding, followed by mild purges, diluent drinks, 
and, in the latter periods, by stimuli and cordials. " This 
method," he says, "has been and may probably be thought by 
some others too simple and easy to conquer so violent and for- 
midable a disease. What! only bleed once or twice, and give 
a little warm water, and two or three simple purges, and this 
simple julep, to subdue such a terrible disease ! without any fine 
boluses, cordial volatiles, and vesicatories ! But I must tell such 
persons that the more simple the method is, if it be but judiciously 
and fitly adapted to the nature and cause of the disease, it is so 
much the better." 1 One hardly knows what to make of his state- 
ment that in a practice of eight years he had seen only two 
patients, treated in this manner, die! The American edition 
contains no clue to the period of time during which the observa- 
tions were made, but as an oifset to this and all other omissions, 
it is well barnacled over with notes by its illustrious editor. 

A Treatise on Tropical Diseases, etc. By Benjamin Mosely, 
M. D. London. Dr. Mosely's work was first published in 1787 ; 
thus preceding, by several years, the great epidemic period of 
yellow fever which commenced in 1793. It is quite miscellaneous 
in its contents ; — containing remarks on military operations in 
the West Indies; on dysentery; on the endemial causus, as he 
calls it, or yellow fever; on tetanus, and other diseases; and, 
finally, on the influence of the moon. I know nothing of the 

1 Rush's Hillary, p. 125. 



BIBLIOGRAPHY. — HUNTER. — CHISHOLM. 567 

personal history or character of Dr. Mosely; but his book, 
notwithstanding its faults — its lumber of learning, its parade of 
ancient error and credulity, and its want of method — is one of 
the raciest, freshest, and most entertaining, in medical literature. 
Dr. Mosely expresses his disbelief in the contagiousness of all 
forms of pestilential fever. He looks upon yellow fever as 
totally different from the bilious remittent. His description of 
the disease is short, but exceedingly vivid and striking. His 
treatment was by free and repeated bleeding, at the commence- 
ment, followed by the warm bath, and saline purges, diaphoretics, 
and large quantities of cinchona. In the second stage, he insists 
upon the necessity of still further purging. 

Observations on the Diseases of the Army in Jamaica, etc. 
By John Hunter, M. D., F. R. S., etc. London, 1788: pp. 
315. Dr. Hunter had the care of the British Military Hospitals 
in the island of Jamaica, from 1781, to 1783; and this little 
book contains the results of his medical experience, during this 
period of time. The work is marked throughout by close obser- 
vation and sound sense; although it adds but little to our 
knowledge of yellow fever. He did not regard the disease as 
essentially different from bilious fever ; and he saw no evidences 
of its transmissibility by contagion. 

Practical Observations on the Diseases of the Army in 
Jamaica, etc. By William Lempriere. London, 1790. 2 vols., 
pp. 652. Lempriere was regimental surgeon, and superintendent 
of the military hospitals, in Jamaica, from 1792 to 1797. His 
book is well and sensibly written. He calls yellow fever tropical 
continued fever ; recognizes and insists upon its essential unlike- 
ness to bilious remittent fever, and denies its contagiousness. 
His description of the disease is very good. His treatment 
consisted mostly in the warm bath, a mercurial purgative, and 
cinchona. His chapter on the pathology of yellow fever is 
wholly hypothetical and speculative, and of no value whatever. 

An Essay on the Malignant Pestilential Fever, introduced 
into the West Indian Islands, from Boullam, on the Coast of 
Guinea, as it appeared in 1793, 1794, 1795, and 1796, etc. etc. 
By 0. Chisholm, 31. D. Dr. Chisholm was a resident at Grenada 
during the prevalence in that island of the disease which he de- 
scribes. He may be looked upon as the leader of the contagionists, 
and he was one of the most earnest advocates of the mercurial 



568 YELLOW, FEVER. 

« 

treatment of yellow fever. His account of the introduction of 
the disease into Grenada 'has already been given. His descrip- 
tion of the disease is anything but clear and complete. He 
looked upon the new fever as essentially distinct from the ordi- 
nary yellow fever of the West Indies; and he seems to have 
been constantly haunted by the notion of its close resemblance 
to the Oriental plague. 1 His work constitutes an interesting 
portion of the history and literature of yellow fever, notwithstand- 
ing its incompleteness and one-sidedness. 2 The distinctions which 
he endeavors to make out between the two diseases are altogether 
fanciful, as well as his speculations upon their causes. His treat- 
ment was founded upon what he calls reasoning and reflection. 

A Sketch of the History and Cure of Febrile Diseases in the 
West Indies. By Robert Jackson, M. D. London, 1820. 2 
vols. 2d ed. There is hardly any work on the diseases of the 
West Indies which has enjoyed a more extensive celebrity than 
this ; and there is none which has less real value. There are some 
indications in it of good sense ; but its leading characteristics are 

1 After pointing out this resemblance in detail, the Doctor winds up with the 
very sage and satisfactory conclusion, that yellow fever is quite like the plague, 
except that it does not always exhibit the symptoms of the latter malady! 

2 There is a good deal of inherent evidence in Dr. Chisholm's book, that much 
of what he says is to be taken with seme grains, at least, of allowance ; even 
when he supposes himself to be relying upon the clear evidence of his own senses. 
In his account of the first autopsy that he made, he says : " The upper part of the 
cranium, on being sawed and prised up by a chisel, was so pressed from inwards 
by the distension of the cerebrum as to fly off, or separate in such a manner as if 
a spring from within acted upon it." The worthy Doctor believed, also, in the ex- 
istence of the mermaid, with all the interesting and lady-like qualities usually as- 
signed to her; the head, like that of the human species, but rather smaller, some- 
times bare, but oftener covered with an abundance of long, black hair ; the shoulders 
broad, and the breast large, and well formed; the tail, fish-like, and forked, and 
so on. These creatures were generally seen in a sitting posture in the water, their 
tails, very properly, out of sight ; and always employed in smoothing their hair, 
or stroking their breasts and faces with their hands. They are held in great ve- 
neration by the natives, and this is the reason that none of them have ever been 
shot. Such is the account which a Mr. Van Battenburgh gave to Dr. Chisholm, and 
which greatly diminished the skepticism of the latter in regard to this subject. 
— Chisholm's Essay, vol. ii. p. 192. The Doctor thinks it not a little singular, 
that, in yellow fever, a very distressed feeling about the heart— probably a smo- 
thering of the heart — should be peculiar to the natives of Ireland ! Some notion 
of Dr. Chisholm's skill in diagnosis maybe derived from the fact of his describing 
what he calls an Epidemic Polypus, prevailing at Grenada, and characterized by 
the presence of long polypi in the heart and large bloodvessels. 



BIBLIOGRAPHY. — JACKSON. — RUSH. 569 

these — a wretched want of all diagnosis; a spurious and misera- 
ble medical philosophy; an extravagant system of practice; and, 
running through the whole, an utterly unmeaning or unintelligible 
jargon. Dr. Jackson's medical philosophy appertains to the same 
school and class as that of Dr. Rush. He calls yellow fever 
pneumonia, scrofula, and chronic ulcers of the legs; for 
merely, of febrile disease — a kind of pathological unitarian lam 
that would have delighted the heart of the great American. 

The second volume of Dr. Rush's Medical Inquiries is mostly 
devoted to the yellow fever. The author was one of the leading 
medical men in the city of Philadelphia, during the prevalence of 
the disease there, in 1793, and subsequently; he studied it with 
zeal and enthusiasm ; he took a very prominent part in the dis- 
cussions which arose, especially in regard to its causes, and its 
treatment ; and his high position and wide reputation gave to his 
opinions great weight and authority. His account of the epidemic 
of 1793 occupies more than one hundred and fifty pages. It is 
unmethodical and fragmentary; but it contains much valuable 
material for the history of the disease, and will always be read 
with interest and instruction. At the commencement of the epi- 
demic, Dr. Rush adopted the treatment recommended by Dr. 
Stevens, by Peruvian bark, and the cold affusion. Three out of 
four of his patients died. He meditated and studied ; and the first 
rays of the true light, as he regarded it, seem to have been de- 
rived from a manuscript account of the yellow fever of Virginia, 
in 1741. He now began the use of calomel and jalap, and four 
of his first five patients recovered. He assured his fellow-citizens, 
that the disease was no longer incurable. He soon added to this 
treatment bleeding, cool air, cold drinks, low diet, and cold water 
externally. "Never before," exclaims the enthusiastic philan- 
thropist, " did I experience such sublime joy as I now felt in 
contemplating the success of my remedies. It repaid me for all 
the toils and studies of my life." The most lamentable defect in 
these histories of the yellow fever consists in the absence of all 
accurate diagnosis. A case of ordinary menorrhagia, or colic, is 
called a form of yellow fever ! This defect, with a most unphi- 
losophical passion for hasty and unwarrantable generalization, 
takes away much of the value which these histories would other- 
wise possess. 



570 YELLOW FEVER. 

A Short Account of the Malignant Fever, lately prevalent in 
Philadelphia, etc. etc. By Matthew Carey. 4th ed. Phila- 
delphia, 1794. This is an interesting history — moral, social, 
and statistical, rather than medical, of the epidemic of 1793, 
written by a sensible and judicious man, not of the profession. 
The picture of the scene is very vividly and graphically drawn 
— the common picture of pestilence, with its shapes of darkness, 
and its shapes of light; abject terror, selfishness, and inhumanity, 
strangely mingling and contrasting with the boldest courage, self- 
forgetfulness, and love stronger than death. A large hospital 
was established at Bush Hill. It was crowded with the sick and 
dying, whose perils and sufferings were increased for want of 
suitable nurses and attendants. Amongst those whose personal 
services were voluntarily offered, was a rich merchant, a native 
of France. He took charge of the sick wards; reformed the, 
whole character of the service ; encouraged and solaced the 
patients ; held the cup to their parched lips ; wiped the cold 
sweat from their pale foreheads ; and shrunk from no menial 
office that could mitigate or soften their distresses. This was 
Stephen Girard ; and this simple memorial of him, in the pages 
of Mr. Carey, is a nobler and prouder monument to his memory, 
than that marble temple — magnificent and beautiful as it is — 
which now bears his name. 

Memoirs of the Yellow Fever of Philadelphia in 1798. By 
William Currie. Philadelphia, 1798. This is a kind of desultory 
diary of the yellow-fever visitation of 1798 — a record, from day 
to day, of some of the principal events and incidents of the epi- 
demic. Although public attention and medical research have 
been more particularly directed to the Philadelphia fever of 1793, 
it appears that the epidemic of 1798 was absolutely nearly as 
destructive as the former, and relatively much more so. The 
disease, in the latter year, was more malignant and fatal than in 
the former ; the total mortality was nearly four thousand; although 
three-quarters of the inhabitants are estimated to have left the 
city. This year the disease prevailed more generally along the 
northern than along the southern coast. Dr. Rush has a letter in 
the book, referring fatal cases to the stagnation of acrid bile in the 
gall-bladder, or its close adherence to the upper bowels ; and recom- 
mending an artificial cholera morbus, excited about the fourth day 
of the fever, by shaking the gall-bladder and bowels, and discharg- 



BIBLIOGRAPHY. — CURRIE. — J. DEVEZE. 571 

ing their contents, with tar tar -emetic, gamboge, jalap, and calomel, 
and perhaps Turpeth mineral ! " As there is a blistering point," 
says the philosophical doctor, "in all fevers, so there appears 
to be an emetic point in the yellow fever!" Dr. Curric thinks 
that the fever was introduced into Philadelphia, in the ship Debo- 
rah, from the West Indies. " The contagious nature of the 
fever," he says, " is acknowledged by all, excepting a few 
persons that are distinguished for nothing but the singularity of 
their opinions, and a pertinacious adherence to a tenet which, 
both by the illustrations of reasoning, and the common sense of 
their fellow-citizens, has been declared absurd and untenable." 

A View of the Diseases most prevalent in the United States of 
America, etc. By William Currie. Philadelphia, 1811. 1 vol., 
pp. 240. 

Observations on the Causes and Cure of Remitting or Bilious 
Fevers, etc. By William Currie. Philadelphia, 1798. 1 vol. 

Both these little volumes of Dr. Currie's are marked through- 
out by careful observation, by a correct philosophy, and by sound 
sense. Dr. Currie was a contemporary of Dr. Rush, and a prac- 
titioner in the same city. His general descriptions of disease are 
quite as good, to say the least, as those of his distinguished fel- 
low-citizen, and his medical philosophy infinitely sounder and 
more rational. He recognized clearly the radical difference be- 
tween bilious remittent and yellow fever. He was a qualified 
contagionist, advocating nearly the same doctrines that were sub- 
sequently adopted by Dr. Hosack and others. 

TraitS de la Fievre Jaune. Par Jean Deveze. Paris, 1280: 
pp. 311. Dr. Deveze established himself, as a physician, in St. 
Domingo, in 1778. After a successful and prosperous career of 
fifteen years, he saw his fortune suddenly wrecked by the insur- 
rection in that country, and he was forced to flee for his life. He 
arrived in Philadelphia in August, 1793 and was almost imme- 
diately actively engaged in the treatment of the epidemic then 
prevailing. He was appointed one of the physicians of the hos- 
pital at Bush Hill; but the other medical, men refused to be asso- 
ciated with him; they resigned their places, and he took charge 
of the institution. Dr. Deveze remained in Philadelphia four 
years, so that he saw the two great epidemics of 1793 and 1797. 
He had also been acquainted with the disease, in its sporadic form, 
for fifteen years in St. Domingo. In 1794, he published a short 



572 YELLOW FEVER. 

essay, clearly and strongly controverting the then almost universal 
and popular doctrine of the contagious character of the disease. 
In 1797, he reiterated his opinions in a letter to Governor Mifflin. 
His description of the disease, as it showed itself in 1793,- is short 
and general, but very vivid and cjear. A large portion of Dr. 
Deveze's book is devoted to a consideration of the causes of yel- 
low fever ; and it is his leading object to show that the disease is 
infectious, and not contagious. He is sometimes unsound and un- 
philosophical in his doctrines — as, for instance, when he insists 
upon the identity of all infections or malarial poisons — but his 
book is generally characterized by great fairness, ability, and good 
sense. He writes in a clear, strong, and pure style, and he is 
entirely free from personalities, and from all professional puppy- 
ism — which is something in a work of medical controversy. Dr. 
Rush was a staunch contagionist for several years after the publi- 
cation of Dr. Deveze's essay upon this subject. He at length 
changed his opinions, avowed what he considered his former 
errors, and assigned his reasons for the change ; but no allusion, 
whatever, is made by him to the writings or opinions of Dr. De~ 
veze ; his name is not even mentioned by Dr. Rush ! 

During the first period of the disease, Dr. Deveze gave diluent 
and effervescing drinks, bled very moderately, and made use of 
warm baths, enemata, and emollient applications to the epigas- 
trium. He sometimes applied cold water to the abdomen, and to 
the head. If the disease did not abate, he gave light diffusible 
stimuli, especially sulphuric ether and camphor. To these he 
added nitre. In the second stage, he continued these remedies, 
and added a bitter and tonic infusion, usually of serpentaria and 
cinchona. He also applied blisters and sinapisms ; opened the 
bowels with mild purgatives ; and gave animal broths and rice 
water, to which wine was sometimes added. In the stage of col- 
lapse, the tonic and stimulant remedies were continued, and hot 
applications were made to the limbs. 

A Practical Account of the Mediterranean Fever, etc. By 
William Burnett, 31. D. London, 1816. 1 vol., pp. 522. Dr. 
Burnett was attached to the British fleet, on the Mediterranean 
station, for a period of more than ten years, in the early part of 
the present century. During this time, he had repeated and ex- 
tensive opportunities of studying yellow fever, mostly on ship- 
board, and in the naval and military hospitals. His description 



BIBLIOGRAPHY. — BANCROFT. 573 

of the disease is very good ; but, like that of nearly all other 
writers, very short, and in general terms. His two leading ideas 
are the non-contagious nature of the disease, and the great effi- 
cacy of early and free bleeding, in its treatment. In an Appen- 
dix, of more than a hundred pages, he criticizes, with a good deal 
of asperity, the doctrines and opinions of Mr. Pym — attributing 
to him selfish and mercenary motives, and accusing him of wilful 
misrepresentations. The book, altogether, has but little method 
in its plan and arrangement; and adds but little to our accurate 
knowledge of yellow fever. Like most of the polemical writings 
upon this subject, it is too thoroughly partisan in its character to 
be entirely trusted. 

An Essay on the Disease called Yclloiv Fever, etc. etc. By 
Edivard Nathaniel Bancroft, M. J)., etc.~ London, 1811. 1 vol., 
pp. 81 1. Dr. Bancroft is a strong and unqualified non-contagion- 
ist. He saw something of yellow fever in the West Indies ; but 
does not seem to have studied the disease — except in its etiology 
— with any special care or attention. His remarks on its symp- 
toms, pathology, and treatment are brief, and in no way of any 
great value. The second part of the essay is devoted to the pur- 
pose of showing that animal putrefaction, filth, the crowding of 
persons together in close, unventilated apartments, and so on. are 
incapable, alone, of giving rise to contagious fevers, such as typhus. 
Dr. Bancroft, like most of the non-contagionists of his day, re- 
garded yellow T fever as a high grade, merely, of bilious remittent 
fever. He calls the belief in contagion anti-social and barbarous ; 
and his examination of the opinions of Dr. Chisholm, in connec- 
tion with the Hankey, are marked by a good deal of bitterness 
and asperity. Dr. Bancroft shows very clearly, I think, that the 
disease which affected the crew and people of the Hankey was 
the remittent, and not yellow fever. 

In 1817, Dr. Bancroft published a sequel to his Essay, in nearly 
five hundred pages. He replies particularly to the work of Dr. 
Pym, and again fights the battle of the Hankey: — 

"And thrice he routed all his foes, 
And thrice he slew the slain." 

The work is systematic and elaborate; well written, but rather 
prolix and heavy. 



574 YELLOW FEVER. 

Reports of the Pestilential Disorder of Andalusia, which ap- 
peared at Cadiz in the years 1800, 1804, 1810, and 1813, etc. etc. 
By Sir James Fellowes, 31. D. London, 1815. 1 vol., pp. 484. 
Sir James Fellowes was at the head of the medical department of 
the British armies in the Peninsula, during the war with France. 
He is a decided but dispassionate and rational advocate of the 
doctrine of contagion. He saw yellow fever at different places 
in Spain, but mostly at Cadiz and Gibraltar. There is no evi- 
dence, in his book, that he had studied the disease with any great 
care or thoroughness, and he has hardly added anything to its 
natural history. The proofs which he adduces of its contagious- 
ness, and which he calls incontrovertible, seem to me to be any- 
thing but such. He copies from Arejula a very good general 
description of the disease, as the latter saw it at Cadiz in 1800. 
The temper and style of his book are dignified and gentlemanly; 
and this is something, in a controversy which has sometimes been 
conducted, to use his own words, "with an asperity of lan- 
guage alike disreputable to science and injurious to philosophi- 
cal inquiry." 

Elements of Medical Logic. By Sir Grilhert Blane. London, 
1829. The latter part of this very elegant and philosophical 
essay is devoted to a vindication of the contagious character of 
yellow fever ; and no one acquainted with the previous writings 
of the author, or with his clear, acute, and logical mind, could 
doubt for a moment that the vindication would be made not only 
with fairness and candor, but also with signal ability. Blane 
himself had seen but little of the disease ; it rarely occurred dur- 
ing his service on the West India station; and his convictions 
are, for the most part", the result of a careful and conscientious 
examination of all the trustworthy evidence which he was able to 
procure. It is not improbable that, in some remarks upon the 
report of the French commissioners to investigate the disease at 
Cadiz, he may have had some reference to his own position. " It 
has been objected," he says, " that those commissioners were 
not on the spot when the epidemic prevailed. If this objection 
were well founded, it would go to invalidate all judicial investi- 
gations whatever. It is not deemed a necessary qualification for 
a judge on the bench that he should have been actually present 
at the transactions upon which he is to decide. On the contrary, 
by an accurate and comprehensive survey of the points and bear- 



BIBLIOGRAPHY. — DOUGHTY. — DICKINSON. — BALLY. 575 

ings of a complex case, he is better qualified to form an opinion 
than the actual actors in them, besides being divested of preju- 
dice. It is requisite, for the forming of a clear, calm, and impar- 
tial judgment, that objects, whether natural or moral, should be 
placed at a certain distance, in order that they may be seen in 
those relative positions and bearings, which the eye and mind of 
a close observer, or of a party concerned, is incapable of taking 
in." The general argument for the contagiousness of yellow 
fever is clearly, fairly, systematically, earnestly, and strongly 
stated. The opposite doctrine, he calls " a deplorable and mis- 
chievous delusion" and the reasons upon which it rests, " a piece 
of cavilling sophistry." " The question," he says, in conclu- 
sion, " seems now to be brought to such a point that we may 
venture to challenge any candid, intelligent, and unbiased man, 
whether in or out of the profession, to open his eyes, and deny 
that this disease is contagious ; and if it be not, then has the 
author of this discussion lost every faculty of distinguishing truth 
from falsehood, of discerning light from darkness." 

Observations and Inquiries into the Nature and Treatment of 
the Yellow or Bulam Fever, etc. By Edward Doughty. London, 
1816. 1 vol., pp. 238. Mr. Doughty was in the medical service 
of Great Britain, in Jamaica, during a period of eight years, at 
the beginning of the present century ; and he was at Cadiz in the 
epidemic season of 1810. He was one of the surgeons in the 
staff under Sir James Fellowes ; he wished to study the pathology 
of yellow fever by examinations after death, to which objections 
were made by the latter; Dr. Doughty was guilty of some alleged 
rudeness towards his official superior, and was in consequence 
dismissed from the service. There is nothing new in his book. 
He is an advocate for early bleeding ; and a zealous non-con- 
tagionist. 

Observations on the Inflammatory Endemic, commonly called 
Yellow Fever, etc. By Nodes Dickinson. London, 1819. Mr. 
Dickinson was extensively familiar with the disease about which 
he writes, during a practice of twenty years in the West Indies. 
His work is diffuse, and of no special value. 

Du Typhus a" Amerique, ou Fievre Jaune. Par Vr. Bally. 
Paris, 1814 : pp. 623. This is a systematic treatise on yellow 
fever, by a French physician, who seems to have had extensive 
opportunities for studying the disease in the West India Islands. 



576 YELLOW FEVER. 

He is a contagionist. He made a considerable number of au- 
topsies. The liver, he says, was frequently natural ; yellow in 
two cases, and pale in one. His description of the disease is 
systematic, detailed, and admirable. His treatment has. nothing 
very special; it is moderately antiphlogistic during the first stage ; 
and stimulating and cordial subsequently. 

Observations upon the Bulam Fever, etc. etc. By William 
Pym, Esq. London, 1815: pp. 307. This work is made up 
of running and desultory commentaries upon various subjects con- 
nected with yellow fever. The author examines at considerable 
length, and endeavors to controvert the opinions of Dr. Bancroft 
and Dr. Burnett. He is a very zealous contagionist ; and he finds 
one of the strongest grounds for his opinion on this subject in the 
non-liability of persons to second attacks of the disease. He is 
no friend to the lancet. 

Remarks on the Yellow Fever of the South and Fast Coasts of 
Spain, etc. By Thomas 0' 'Halloran, M. B. London, 1823 : pp. 
208. Dr. O'Halloran was for many years connected with the 
medical service of the British government, and had frequent op- 
portunities of seeing yellow fever in the West India Islands and 
in Spain. During the extensive and malignant epidemic of 1821, 
he visited many of the principal yellow-fever localities of the south 
and east coasts of Spain, for the express purpose of studying the 
disease. The book before us is the fruit of these studies. It con- 
tains medico-topographical sketches of Barcelona, Tortosa, Ma- 
laga, Puerto de Santa Maria, Xerez, Lebrixa, San Lucar, and 
Cadiz ; with remarks on the origin and causes of the epidemic in 
these several towns and cities. The author is a zealous and un- 
qualified non-contagionist. 

Less than twenty pages, constituting, however, a very interest- 
ing and valuable portion of the book, are occupied with an account 
of his pathological researches in yellow fever. He says that he 
had seen more than two hundred dissections in this disease ; but 
he reports only eleven. Sufficient reference to these has already 
been made. He says that the examination of yellow-fever sub- 
jects ought to take place as soon as possible after death ; since 
the different organs, and more particularly those which have suf- 
fered from the disease, undergo changes in a few hours, so as to 
become brown, black, and apparently gangrened. 



BIBLIOGRAPHY.— UOSACK. — DANIELL. — WILSON. 577 

Essays on Various Subjects of Medical Science. By David 
Hosack, M. D., F. B. S., etc. New York, 1824 : 2 vols. The 
first volume of these miscellaneous Essays contains Dr. Ilosack's 
Observations on the Laws which govern the communication of 
Contagious Diseases. The leading objects of the Essay are to 
show that yellow fever is not the product of miasmata, or of any 
animal or vegetable decomposition; but that it depends upon a 
specific virus, which is generated by the disease in the human 
body ; and that this virus, when introduced into a local atmo- 
sphere already vitiated by vegetable and animal impurities, is 
endowed with the property of indefinitely multiplying itself ; 
or, in other words, by a kind of fermentative process assimilating 
the impure atmosphere to itself. In this atmosphere, according 
to Dr. Hosack, but not elsewhere, yellow fever is communicable 
from the sick to the well. 

Observations upon the Autumnal Fevers of Savannah. By W. 
C. Daniell, M. D. Savannah, 1826. The principal- purposes 
of Dr. Daniell's publication are to state some new views of the 
nature and pathology of autumnal fevers, and to recommend a 
somewhat novel method of treatment. The former consist alto- 
gether of hypothetical rationalism ; and the chief element of the 
latter consists in producing extensive and continued inflammation 
of the skin by sinapisms. All success in the treatment of autum- 
nal fever, yellow fever included, depends upon this inflammation 
of the skin. What leeches w T ere to Broussais ; what the lancet is 
to Bouillaud ; and what quinine is to many of our southwestern 
physicians, sinapisms are to Dr. Daniell. His other remedies are 
capsicum, serpentaria, and Peruvian bark. He insists earnestly 
upon the congestive and non-inflammatory nature of yellow fever ; 
and he argues that all its phenomena, symptomatical and patho- 
logical, go to corroborate this doctrine. He is opposed to bleed- 
ing, to mercurials, and to active purging. 

Memoirs of the West Indian Fever, etc. etc. By John Wilson, 
M. D., B. N. London, 1827: pp. 217. This is one of the great 
numbers of valuable contributions which have been made to 
medical science by the medical officers of the British army and 
navy. Like most other works of the class to which it belongs, it 
is partial in its design, and somewhat fragmentary in its charac- 
ter ; it does not profess to be a systematic treatise on the subject 
with which it is concerned, but it furnishes valuable materials for 
37 



578 YELLOW FEVER. 

the construction of such a treatise. It consists of five separate 
Memoirs. The first is devoted to a general description of the 
several forms of yellow fever, and to the methods of treatment 
which they respectively require. Dr. Wilson's descriptions I 
have already quoted. In the inflammatory forms, he is a bold 
and active bleeder ; in the congestive forms, he has little faith in 
remedies, but would try hot and stimulating applications to the 
skin ; warm, aromatic, and cordial drinks, a warm purgative, and 
calomel in large and repeated doses. 

In the second Memoir, Dr. Wilson examines some of the lead- 
ing opinions in regard to the causes of yellow fever, especially 
those which have referred the disease to atmospheric heat, to con- 
tagion, to marsh miasmata, and to the principle of vegetation. 
All these opinions he rejects. 

In the third Memoir, he states his own opinions about the cause 
of the disease. He suggests, in the first place, that this cause 
may be in some way connected with a calcareous formation of 
the soil, since the principal yellow-fever localities in the West 
Indies, he says, have a soil of this character. The essential 
cause, he believes, is furnished by wood, consisting in a gaseous 
product of trees and shrubs, in a state of decomposition, generally 
given out by them in a cut or dried state, but which may arise 
from a living forest, trees being capable, in different parts of their 
frame, of simultaneous growth and decay. 

In the fourth Memoir, Dr. Wilson states very clearly some of 
the more obvious reasons for regarding yellow fever as a distinct, 
specific disease, and not an aggravated variety of merely bilious 
remittent. 

The fifth Memoir consists of a few remarks upon the nature of 
yellow fever, and upon the manner in which the cause of the 
disease acts upon the body. Of course, it is mostly hypothetical; 
but it is less unreasonable than most speculations of a similar 
character. 

De V Opinion des Medecins Americains sur la Contagion ou la 
Non-Contagion de la Fiivre Jaune, etc. etc. Par N. Chervin. 
Paris, 1829 : pp. 192. It is hardly worth while to enumerate the 
titles of all the different works published by M. Chervin on the 
subject of the yellow fever. The character of these works, and 
the history of his life and labors, are well known to all those who 
have made this disease a subject of study. He was the great 



BIBLIOGRAPHY. — LOUIS. — WILLIAMS. — ANDREWS. 579 

champion of non-contagion in the Old World; and nearly the 
whole of the five volumes which he published, between 1827 and 
1840, is devoted to the vindication of his favorite doctrine. The 
volume whose title I have given is mostly taken up with his re- 
plies to Dr. Hosack and Dr. Townsend, of New York. It is pain- 
ful and humiliating to witness the violence* and harshness of this 
controversy. 

Anatomical, Pathological, and Therapeutic Researches on the 
Yellow Fever of Gibraltar of 1828. By P. Ch. A. Louis. Bos- 
ton, 1839: pp. 374. The history of this remarkable work is well 
known. It was first presented to the public, in an English trans- 
lation, by Dr. G. 0. Shattuck, Jr., of Boston, in 1839, more than 
ten years after its materials were collected. Since that time, it 
has been published in the original French, in the second volume 
of the Transactions of the Medical Society of Observation. It 
does not profess to be a systematic treatise on yellow fever ; in- 
deed, it is only a partial history of a single epidemic, many points 
in the natural history of the disease being wholly omitted. Still, 
as a description of the symptoms and lesions of yellow fever, it 
is of very great value, and no history of the disease can be ren- 
dered complete without constant reference to its pages. 

The New Orleans Medical Journal contains numerous papers 
on yellow fever, some of which are of much value ; they have al- 
ready been laid under liberal contribution in the preceding his- 
tory. I will briefly refer to the principal ones amongst them. 
First, an Essay on Yellow Fever, by J. F. Beugnot. It is written 
in the English language, but in the French idiom ; and is the 
work, I presume, of a French physician. It is mostly taken up 
with the subject of treatment. Dr. Beugnot's leading object is to 
show the importance of what he calls syncopal bloodletting in the 
treatment of yellow fever. He gives to Dr. Luzenburg the credit 
of originating this practice. The evidence of the efficacy of this 
method consists merely in general assertion, and is of course in 
no degree conclusive or satisfactory. Second, An Account of the 
Yellow Fever at Rodney, in 1843, by Dr. Williams and Dr. An- 
drews. Rodney is a small town on the east bank of the Missis- 
sippi, forty miles above Natchez. It was visited by the yellow 
fever, for the first time, in 1843. The authors of the paper be- 
lieve that the disease did not originate from local causes, but was 
introduced from New Orleans. Third, an article by Dr. Lambert. 



580 YELLOW FEVER. 

of twenty pages. This is in good part an attempt to give the rea- 
sons of many of the phenomena and relations of the disease; and 
it is as successful and satisfactory, perhaps, as such attempts usu- 
ally are. Fourth, Thoughts on Yellow Fever, etc., by Dr. P. 
H. Lewis, of Mobile. This is a reply to the arguments of Dr. 
Monet te, and Dr. Carpenter, who advocate the transportability of 
the poison of yellow fever. Dr. Lewis does not admit that it ever 
possesses this property. Fifth, A Report on the Yellow Fever at 
Woodville, by Br. De Valetti, and Dr. Logan. Woodville is a 
small inland town in the State of Mississippi, about fifteen miles 
in a direct line from the Mississippi River. In 1844, it was visited 
by yellow fever, and the usual differences of opinion arose in re- 
gard to the cause and origin of the disease. In this paper, it is 
ascribed to domestic sources. Sixth, Sketch of the Yellow Fever 
of Mobile, etc., by P. H. Lewis, M. D. This sketch consists of 
two long articles. Notwithstanding its want of method, and its 
hasty preparation, it contains much matter of importance and 
value. I have made free use of its materials in the preceding 
history. Seventh, A Report, by Dr. Stone, on the Origin of the 
Woodville Epidemic, with a Discussion groiving out of the Report 
before the Louisiana Medical Society. Dr. Beugnot states that 
Woodville possesses in the highest, degree every condition essen- 
tial to salubrity ; a silicious soil, an elevated position, a dry atmo- 
sphere, moderate temperature, and so on. He is a decided anti- 
contagionist; but he is not less decided in his conviction, that the 
seeds of the poison may be transported from one place to another 
— multiplying and extending themselves in the locality where they 
are introduced. He advocates quarantine for ships, and their 
cargoes, but not for persons. Dr. Luzenburg expresses his sus- 
picions that the fever at Woodville was introduced from New Or- 
leans, or Bayou Sara, during the present year, in boxes of mer- 
chandise, or possibly some years previously in goods which had 
not been opened. Dr. Stone's report contains a full account of 
the Woodville epidemic. 

In the second volume, there are the following papers : First, 
Practical Remarks on the Yellow Fever which prevailed at Ope- 
lousas, in 1837, 1839, and 1842; by Dr. Cooke: Dr. Cooke be- 
lieves that the poison of the disease is generally introduced from 
New Orleans. Second, a sketchy, interesting, sensible paper, his- 
torical, topographical, critical, and so on, by Dr. Dowler of New 



581 

Orleans. Third, Remarks on Yellow Fever, by Dr. Harrison. 
The author praises, almost extravagantly, the sulphate of quinine. 
He deprecates, in the strongest terms, the mercurial practice; 
and says that general bleeding is only an exceptional remedy, and 
always to be used with great caution and reserve. Fourth, An 
Account of the Yellow Fever at New Orleans, in 1846, by Dr. 
Fenner. The author concludes that the disease was of domestic 
origin; and that the prevalence of summer fevers in the city is 
not in proportion to the amount of heat, moisture, and putrid mat- 
ters. Fifth, Cases showing the Effect of Yellow Fever on the Sys- 
tem for a long period after an attack, by Dr. Stone, of Natchez. 
This is an important subject; but the cases given by Dr. Stone 
can hardly be regarded as conclusive. Sixth, An Account of the 
Yellow Fever at Woodville, by Dr. Stone, of Woodville. The 
most singular thing in this paper is the unqualified confidence 
with which the writer speaks of his method of treatment. He 
bled, at the beginning, freely and repeatedly ; and then gave what 
he calls sedative doses of calomel, usually from forty to sixty 
grains. This remedy, thus used, Dr. Stone regards as a specific 
just as absolute and efficacious in yellow fever as quinine is in 
intermittents ! 

There are several interesting and valuable articles in the Ame- 
rican Journal of Medical Sciences, by Dr. E. H. Barton, Dr. E. 
B. Harris, Dr. Barrington, Dr. Nott, and others. 

The article in the Cyclopedia of Practical Medicine is by Dr. 
J. Gillkrest. The author begins with quotations from Dr. Rush, 
and from British and Spanish physicians, tending to show that 
yellow fever sometimes assumes a remittent type. He next gives 
a short but interesting historical sketch of the disease in Europe 
and America, showing clearly enough that yellow fever prevailed, 
often and extensively, as long ago as the sixteenth and seventeenth 
centuries. Dr. Gillkrest is a strong anti-contagionist ; and he de- 
tails many striking facts which fell under his own observation at 
Gibraltar, in proof of his opinions on this subject. He seems to 
think highly of the mercurial treatment. 

The paper in the Library of Practical Medicine is by Dr. Shap- 
ter. It is much shorter, and less elaborate, than that of Dr. Gill- 
krest. 



INDEX 



Abdomen, state of, 

bilious fever in, 363 

typhoid fever, 77 

typhus fever, 215 

yellow fever, 467 
Abdominal lesions, 

periodical fever in, 372 

typhoid fever, 90—103 

typhus fever, 232—237 

yellow fever, 480—491 
Abdominal pains, 

typhoid fever in, 76 

typhus fever, 217 

yellow fever, 467 
Abdominal symptoms, 

bilious fever in, 361 — 366 

congestive fever, 404 

typhoid fever, 72—78 

typhus fever, 213— 217 

yellow fever, 464 — 468 
Abdominal typhus, 51, 2SS 
Access, mode of, 

bilious fever, 350 

congestive fever in, 399 

typhoid fever, 56, 139 

typhus fever, 200 

yellow fever, 458 
Access, period of, 

periodical fever in, 353 

yellow fever, 459 
Acclimation, 

periodical fever in, 396 

yellow fever, 506 
Affusions and ablutions, 

congestive fever in, 435 

typhoid fever, 173, 175 

typhus fever, 328 

yellow fever, 557 
African fever, 450 

climate, 452 

diseases, 452 
Age, influence of, 

periodical fever on, 390 

typhoid fever, 124, 143, 282 

typhus fever, 252, 265, 282 

yellow fever, 502, 544 
Algid fever, 402 

Alteratives in typhoid fever, 171, 185 
Alum in typhoid, 184 
Anderson, Dr., 375 
Andral, 155, 157 
Andral and Gavarret, 86 
Anaemia, 414, 443 



Animalcular hypothesis, 393 
Animal decomposition, 393, 513 
Annesley, Dr., 449 
Antimony, 

typhoid fe\er in, 168, 172 

typhus fever, 331 ' 
Antiphlogistic treatment, 

yellow fever in, 555 
Aorta, lesions of, 85 
Appetite, 

bilious fever in, 362 

typhoid fever, 73 

typhus fever, 214 

yellow fever, 464 
Armstrong, Dr.. 245, 278 
Arnold, Dr., 489, 490 
Arrott, Dr., 243, 253 
Autenrieth, Dr., 288 

Bancroft, Dr., 555, 573 

Bailly, Dr., 370, 448 

Bally, Dr., 575 

Barbour, Dr., 434 

Barker, Dr., 19S, 339 

Barrington, Dr., 45S, 525 

Bateman, Dr., 269, 340 

Bed-sores, 17S 

Beugnot, Dr., 579 

Bibliography of periodical fever, 446 — 453 

Alibert, 448 

Annesley, 449 

Baillv, 44S 

Boyle, 452 

Brown, J., 453 

Cleghorn, 446 

Drake, 453 

Johnson, J., 447 

Lind, James, 447 

Macculloch, 44S 

Maillot, 449 

M'William, 450 

Senac, 446 

Shapter, 453 
Bibliography of typhoid fever, 190 — 194 

Chomel, 193 

Forget, 193 

Hale, 193 

Jackson, J., 193 

Jenner, 194 

Louis, 192 

Prost, 190 

Smith, N., 192 
Bibliography of typhus fever, 337—344 



584 



INDEX. 



Bibliography of typhus fever — continued. 

Barker and Cheyne, 339 

Bateman, 340 

Cheyne, 343 

Christison, 343 

Clutterbuck, 338 

Cormack, 342 

Gaultier de Claubry, 341 

Harty, 339 

Hildenbrand, 338 

Jackson, R., 340 

Mills, 338 

Percival, 341 

Prichard, 341 

Pringle, 337 

Reid, 344 

Smith, 343 

Trotter, 337 

Tweedie, 343 
Bibliography of yellow fever, 565 — 581 

Amer. Journ. of Med. Sci., 581 

Bally, 575 

Bancroft, 573 

Blane, 565, 574 

Burnett, 572 

Carey, 570 

Chervin, 578 

Chisholm, 567 

Currie, Wm, 570, 571 

Daniel!, 577 

Deveze, 571 

Dickinson, 575 

Doughty, 575 

Fellowes, Sir J., 574 

Gillkrest, 581 

Hillary, 566 

Hosack, 577 

Hunter, J., 567 

Jackson, R., 568 

Lempriere, 567 

Louis, 579 

Mosely, 566 

N. O.Med. Journ., 579 

O'Halloran, 576 

Pym, Sir W., 576 

Rush, 569 

Shapter, 581 

Wilson, 577 
Bile, character of, 

periodical fever in, 377 

typhoid fever, 103 

typhus fever, 234 

yellow fever, 489 
Bilious remittent fever, 349—397 
Biles in typhoid fever, 83 
Bis-feriens pulse, 62 
Black vomit, 466, 481, 484 
Blane, Sir G., 202, 332, 472, 525, 562, 565, 

574 
Blisters, 

typhoid fever in, 173, 177, 181, 185 
Bloodletting, 

bilious fever in, 429 

congestive fever, 435 

typhoid fever, 172, 175, 180, 181, 
182 



Bloodletting — continued. 

typhus fever, 324—328 

yellow fever, 555 
Blood, state of, 

periodical fever in, 368 

typhoid fever, 86, 165 

typhus fever, 224, 229 

yellow fever, 479 
Boling, Dr., 350, 355, 358, 364 
Bouillaud, 182 
Bowels, state of, 

bilious fever in, 364 

congestive fever, 404 

typhoid fever, 74 

typhus fever, 215 

yellow fever, 467 
Boyle, Dr., 452 
Bracken, Dr., 258 
Brain, lesions of, 

periodical fever in, 368 

typhoid fever, 89 

typhus fever, 230 ,, 

yellow fever, 480 
Brandy in yellow fever, 559 
British and Foreign Review, 302, 323 
Bronchia?, lesions of, 

periodical fever in, 367 

typhoid fever, 87 

typhus fever, 227 
Broussais, 53, 191 
Brown, Dr. Wm., 334 
Brunner's glands, 380 
Burnett, Dr., 555,572 
Butler, Dr., 239 

Calomel, 

bilious fever in, 431 

congestive fever, 434 

typhoid fever, 168, 171, 173 

typhus fever, 328 

yellow fever, 553 — 555, 558 
Calor mordicans, 202 
Camphor in typhus fever, 332 
Carey, M., 518, 570 
Causes of death, 

periodical fever in, 385, 427 

typhoid fever, 104 

yellow fever, 494 
Causes of periodical fever, 386 — 39 

age, 390 

exposure, &c, 392 

locality, 386 

malaria, 393 

race, 391 

season, 389 

sex, 391 

temperature, 389 

weather, 389 
Causes of typhoid fever, 107—128 

age, 124 

contagion, 120 — 123 

epidemic, 124 

exposure, &c, 128 

filth, crowding, &c, 127 

locality, 107—118 

occupation, 127 



INDEX. 



Causes of typhoid fever — continued. 

race, 126 

recent residence, 127 

season, 118 

second attacks, 123 

sex, 126 
Causes of typhus fever, 238 — 254 

age, 252 

contagion, 243—248 

crowding, filth, &c, 249 

epidemic, 248 

excesses, &c, 249 

famine, 249 

fatigue, 249 

locality, 238 

recent residence, 254 

season, 241 

sex, 253 

weather, 242 
Causes of yellow fever, 495 — 527 

acclimation, 506 

age, 502 

constitution, 505 

contagion, 515 

decaying matters, 513 

epidemic, 510 

essential poison, 526 

exposure, &c, 524 

infected districts, 498 

locality, 495 

marsh miasmata, 512 

occupation, 506 

race, 504 

season, 499 

second attacks, 508 

sex, 502 

sporadic, 511 

temperature, 500 

weather, 500 
Cerebral respiration, 62 
Cerebral symptoms and lesions, 

relations between, 90, 230 
Cerebro-spinal symptoms, 

bilious fever in, 358 

congestive fever, 400 

typhoid fever, 63 

typhus fever, 206 

yellow fever, 469 
Chervin, 578 

Cheyne, Dr. J., 198, 208, 260, 271, 339 
Chills, 

bilious fever in, 351 

congestive fever, 402 

intermittent fever, 406 

typhoid fever, 58, 140 

typhus fever, 201 

yellow fever, 460 
Chisholm, Dr., 515,567 
Chloiide of soda, 

typhoid fever in, 178 
Chomel,57, 132, 163, 174, 193 
Christison, Dr., 248, 343 
Cicatrization of intestinal ulcers, 99 
Cinchona, 

bilious fever in, 431 

congestive fever, 439 



Cinchona — continued. 

typhoid fever, 173, 176 

typhus fever, 330 

yellow fever, 558 
Cities, yellow fever, 496 
Clark, Dr. A., 124 
Cleanliness, 

typhoid fever in, 174, 180, 248 

typhus fever, 248, 334 

yellow fever, 560 
Cleghorn, Dr., 408, 419, 446 
Clutterbuck, Dr., 338 
Coe, Dr., 110 
Cold affusions, 

congestive chill in, 435 

typhoid fever, 173, 175, 

yellow fever, 557 
Collapse, 

congestive fever in, 402 

yellow fever, 536 
Color of skin, 

bilious fever in, 356 

typhus fever, 224, 257 

yellow fever, 474, 491 
Coma, 

congestive fever in, 400 

typhoid fever, 65, 140 

typhus fever, 210, 268 

yellow fever, 471 
Comatose fever, 400 
Complications, 

typhoid fever in, 136 

typhus fever, 255 
Congestive fever, 398—405 

algid, 402 

comatose, 400 

delirious, 401 

gastro-enteric, 404 

mode of attack, 399 

mortality, 416 

names, 398 

prognosis, 416 

treatment, 433 

type, 399 
Constitution, in yellow fever, 505 
Contagion, 

typhoid fever of, 120—123 

typhus fever, 243—248 

yellow fever, 515 — 524 
Contents of gall-bladder, 

periodical fever in, 377 

typhoid fever, 103 

typhus fever, 234 

yellow fever, 489 
Contents of stomach and bowels, 

periodical fever in, 383 

typhoid fever, 92 

yellow fever, 481, 4S4 
Contingent contagion, 519 
Convalescence, 

yellow fever from, 53S 
Cooke, Dr., 390, 580 
Cordials, 

typhoid fever in, 170, 176 

typhus fever, 329 

yellow fever, 558 



586 



INDEX. 



Core, Dr., 109, 152 
Cormack, Dr., 342 
Cough, 

typhoid fever in, 63 

typhus fever, 205 
Critical days, 411 
Crises, 256, 259 
Crowding, 249 

Currie, Dr. Wm., 446, 570, 571 
Cutaneous eruptions, 

typhoid fever in, 79 

typhus fever, 218—224 
Cutaneous sensibility, 

typhoid fever in, 69 

typhus fever, 212—273 

Damaged coffee. 513 
Daniell, Dr., 577 
Darwin, Dr., 2S4 
Davidson, Dr., 254, 296 
Deafness, 

typhoid fever, 69, 141 

typhus fever, 212 
Death, causes of, 

periodical fever in, 384, 427 

typhoid fever, 104 

yellow fever, 494 
Definition, 

periodical fever of, 444 

typhoid fever, 188 

typhus fever, 335 

yellow fever, 563 
De Haen, 285 
De Larroque, 183 
Delirium, 

bilious fever in, 358 

congestive fever, 401 

typhoid fever, 65, 140 

typhus fever, 207 

yellow fever, 470 
Description, methods of, 54 
Desquamation of cuticle, 61 
Deveze, Dr., 519, 571 
Diagnosis, 

congestive fever of, 422 

periodical fever, 422 

typhoid fever, 147 — 158 

typhus fever, 272—321 

yellow fever, 547 — 549 
Diaphoretics, 

bilious fever in, 433 

typhus fever, 331 
Diarrhoea, 

bilious fever in, 363 

typhoid fever, 74, 142 

typhus fever, 216 
Dickinson, Dr., 575 
Dickson, Dr. S. H., 554 
Diet, 

typhoid fever in. 169 

typhus fever, 334 
Differences between, 

bilious and typhoid fever, 152, 422 

typhoid and typhus fever, 273—320 
Difficulty of swallowing, 

typhoid fever in, 73, 91, 142 



Discharges from bowels, 

bilious fever in, 364 

congestive fever, 404 

involuntary, 142 

typhoid fever in, 74 

typhus fever, 216 

yellow fever, 467 
Distension of abdomen, 

bilious fever in, 363 

typhoid fever, 77 
Dizziness, 

bilious fever in, 360 

typhoid fever, 69 

typhus fever, 212 

yellow fever, 470 
Doane, Dr., 239 
Dothinenteritis, 50 
Douglas, Dr., 256 
Doughty, Dr., 500, 575 
Dowler, Dr., 510, 581 
Drake, Dr., 441, 453 
Drinks, 

bilious fever in, 433 

typhoid fever, 170, 173, 175, 177, 180 
Duration, 

periodical fever of, 407 

typhoid fever, 134 

typhus fever, 258 

yellow fever, 533, 538 
Dyspnoea in typhoid fever, 63 

Easterly winds, influence of, 

yellow fever on, 501 
Effects of treatment, 

typhoid and typhus fever, 277 

typhus fever, 334 
Elliptical plates, lesions of, 

bilious fever in, 380 

constancy, 152 

nature of, 161, 165 

typhoid fever in, 93 

typhus fever, 233 
Emaciation, 

typhoid fever in, 78 

typhus fever, 217 
Emetics, 

typhoid fever in, 168, 172, 1S4 

typhus fever, 332 
Enemata, 

typhoid fever in, 168, 175, 180 
Entero-mesenteric fever, 50 
Epidemic influences, 

typhoid fever in, 124 

typhus fever, 248, 268 

yellow fever, 510 
Epigastric tenderness, 

bilious fever in, 363 

typhus fever, 216 

yellow fever, 468 
Epiglottis, lesion of, 88 
Epistaxis, 

treatment of, 177 

typhoid fever in, 79, 141 

typhus fever, 218 

yellow fever, 475 
Eruptions, cutaneous, 



INDEX. 



587 



Eruptions, cutaneous — continued. 

typhoid fever in, 79 

typhus fever, 218, 224, 269 
Erysipelas, 83, 136, 143 
Eschars, 

typhoid fever in, 82 

typhus fever, 224 
Essential poison of yellow fever, 526 
Ether, 

congestive fever in, 438 

typhoid fever, 177 
Exacerbations, 

typhoid fever in, 60 

typhus fever, 202 
Exemption from second attacks, 

typhoid fever in, 123 

typhus fever, 251 

yellow fever, 508 
Expectant treatment, 

typhoid fever in, 172, 175 
Expedition to the Niger, 450 
Exposure, excesses, &c, 

periodical fever in, 392 

typhoid fever, 128, 145 

yellow fever, 524 
Eyes, state of, 

typhoid fever in, 69 

typhus fever, 210 ♦ 

yellow fever, 472 

Falling off of hair, 61 
Famine, 

typhus fever, cause of, 249 
Fearn, Dr., 438 
Febrile symptoms, 

bilious fever in, 351 

typhoid fever, 5S 

typhus fever, 201 

yellow fever, 460 
Fellowes, Sir J., 500, 521, 574 
Fever, 

algid, 402 

bilious remittent, 349 

camp, 199 

comatose, 400 

congestive, 39S 

contagious, 199 

hospital, 199 

intermittent, 406 

jail, 199 

malignant, 199 

periodical, 347 

petechial, 199 

putrid, 199 

remittent, 349, 397 

spotted, 239 

typhoid, 49—194 

typhus, 197—344 

yellow, 457 
Fever, bilious remittent, 349, 397 

diagnosis, 422 — 424 

duration and march, 408 — 414 

mortality, 415 

symptoms, 350 — 365 

treatment, 429 — 433 
Fever, congestive, 398 — 405 



Fever, congestive — continued. 
algid, 402 
comatose, 400 
delirious, 401 
gastro-enteric, 404 
mode of attack, 399 
mortality, 415 
names, 398 
prognosis, 415 

type, 399 
Fever of New England, 51, 107 
Fever, periodical, 347 — 453 

bibliography, 446 — 453 

causes, 3S6 — 396 

definition, 444 * 

diagnosis, 422 

duration and march, 408 — 4!4 

introductory, 347 

lesions, 367—385 

mortality, 415 

names, 349 

prognosis, 416 

symptoms, 350—366 

theory, 425 

treatment, 429 

varieties, 397 — 407 
Fever, typhoid, 

bibliography, 190 — 194 

causes, 107— 12S 

definition, 1SS 

diagnosis, 147 — 158 

duration, march, &c, 134 

history, 52 

lesions, 84—106 

methods of description, 54 

mortality and prognosis, 139 — 146 

names, 50 

relapses, 137 

sequela?, 138 

symptoms, 56 — S3 

theory, 159—166 

treatment, 167 — 187 

varieties, 129 — 133 
Fever, typhoid and remittent, 

diagnosis of, 147 
Fever, typhoid and typhus, 

distinctions between, 14S, 272, 3u7 
Fever, typhus, 

bibliography, 337—344 

causes, 23S— 254 

definition, 335 

diagnosis, 272—321 

duration and march, 25S — 263 

introductory, 197 

lesions, 226—237 

mortality, 264—271 

names, 199 

symptoms, 200 — 225 

theorv, 322 

treatment, 324—334 
Fever, yellow, 455 

mode of access, 458 

names, 457 

symptoms, 458 
Filth, crowding, &c. 

typhoid fever, 127 



588 



INDEX. 



Filth, crowding, &c. — continued. 

typhus fever, 249 

yellow fever, 513 
Flint, Dr., IIS 
Follicular enteritis, 50 
Fomites, 524 
Forget, 57, 97, 193 
Forry, Dr., 3s6 
Frick, Dr., 375 

Gall-bladder, contents of, 

periodical fever in, 377 

typhoid fever, 103 

typhus fever, 234 

yellow fever, 489 
Gastric fever, 50, 343 
Gastric symptoms and lesions, 

relations between, 92 
Gaultier de Claubry, 298, 304, 341 
Gendron, 122 
Gerhard, Dr., 51, 198, 206, 209, 213, 230, 

291 
Gillkrest, Dr., 501, 503, 581 
Gilchrist, Dr., 287 
Graves, Dr., 270 
Gurgling, abdominal, 

typhoid fever in, 78 

Hale, Dr. E., 51,76, 193,289 
Hankey, the, 515 
Harrison, Dr., 581 
Harty, Dr., 254, 339 
Headache, 

bilious fever in, 358 

typhoid fever, 64 

typhus fever, 206 

yellow fever, 458, 469 
Hearing, state of, 

bilious fever in, 360 

typhoid fever, 69 

typhus fever, 212 

yellow fever, 474 
Heart, action of, 

bilious fever in, 357 

typhus fever, 204 

yellow fever, 476 
Heart and aorta, lesions of, 

periodical fever in, 367 

typhoid fever, 84 

typhus fever, 229 

yellow fever, 478 
Heat of skin, 

bilious fever in, 355 

typhoid fever, 59 

typhus fever, 270 

yellow fever, 460 
Hemorrhage from bowels, 

congestive fever in, 404 

typhoid fever, 75, 142 

typhus fever, 216 

treatment of, 177 
Hemorrhage in yellow fever, 475 
Henderson, Dr., 208, 214, 221 
Hiccough, 

typhoid fever in, 70 

yellow fever, 474 



Hildenbrand, 208, 262, 338 
Hillary, Dr., 113,501,566 
History of typhoid fever, 52 
Holmes, Dr. O. W., 387 
Hosack, Dr., 499, 520, 577 
Howard, Dr., 374 
Hudson, Dr., 263, 297 
Hungarian fever, 349 
Hunter, Dr. J., 567 
Huxham, 113, 192, 220, 284, 322 

Identity of typhus and typhoid fever, 272 
Incubation, period of, 

typhoid fever in, 122 

typhus fever, 246 

yellow fever, 540 
Infected districts, 498 
Injections, 

typhoid fever in, 168, 175, 180 
Intermittent fever, 406 
Intestines, lesions of, 

periodical fever in^SSO 

typhoid fever, 92—101 

typhus fever, 232—236 

yellow fever, 483 
Intestinal lesions and symptoms, 

relations between, 101 
Intestinal perforation, 77 
Intestinal ulcerating typhus, 51 
Introductory, 

periodical fever to, 347 

typhoid fever, 49 

typhus fever, 197 
Italian authors, 349, 376 

Jackson, Dr. J., 52, 57, 61, 68, 79, 11a, 

126, 134, 168, 193 
Jackson, Dr. J., Jr., 52 
Jackson, Dr. J. B. S., 52, 154 
Jackson, Dr. R., 340, 568 
Jackson, Dr. S., Ill 
Jenner, Dr., 57, 59, 67, 71, 80, 87, 194, 

201 
Jennings, Dr., 124, 125 
Johnson, Dr. J., 447 

Kimball, Dr. G., 119 

Landouzy, Dr., 299 
Large intestine, lesions of, 

periodical fever in, 383 

typhoid fever, 100 

typhus fever, 333, 242 

yellow fever, 484 
Latent form, 

typhoid fever of, 130 
Latent period of contagion, 

typhoid fever in, 121 

typhus fever, 246 

yellow fever, 540 
Latent period of poison, 

periodical fever in, 395 
Leake, Dr., 110 
Lempriere, 535, 561, 567 
Lenticular spots, 79, 274, 285, 308 
Lesions in periodical fever, 367 — 385 



INDEX. 



589 



Lesions in periodical fever — continued. 

blood of, 367 

brain, 368 

general remarks on, 383 

heart, 367 

importance of, 384 

intestines, 380 

liver, 372—377 

Peyer's glands, 381 

relations, 383 

spleen, 377 

stomach, 378 
Lesions in typhoid fever, 51,84 — 106 

aorta, 84 

blood, 86 

brain, and its membranes, 89 

bronchia;, epiglottis, &c, 88 

children, 103 

general remarks on, 104 

heart, 84 

importance, 104 

large intestine, 100 

liver, 103 

lungs, 87 

lymphatic glands, 101 

pancreas, salivary glands, 

urinary and sexual organs, 103 

perforation, 95 

Peyer's glands, 94 

pharynx and oesophagus, 90 

small intestines, 92 

spleen, 102 

stomach, 91 
Lesions in typhus fever, 226 — 237 

blood of, 229 

brain, 230 

general remarks on, 236 

heart, 229 

intestines, 232, 234 

introductory to, 226 

liver, 233 

lungs, 227 

mesenteric glands, 233, 234 

miscellaneous, 236 

Peyer's glands, 233, 234 

petechia?, 236 

spleenr233, 234 

stomach, 232, 236 
Lesions in yellow fever, 477 — 494 

blood, 479 

brain, &c, 480 

contents of stomach, 481 

gall-bladder, 489 

general remarks, 491 

heart, 478 

intestines, 483 

liver, 484 

lungs, 477 

mesenteric glands, 491 

spleen, 491 

stomach, 4S0 

urinary organs, 491 
Letter from, 

Coe, Dr., 110 

Core, Dr., 109, 352 

Darwin, Dr., 284 



Letter from — continued. 

Jennings, Dr., 124, 126 

Kimball, Dr., 119 

Leake, Dr., 110 

"Linton, Dr., 110 

Mattingly, Dr., 108 

Power, Dr., 306 

Sutton, Dr., 109 

Vaughan, Dr., 284 

Wooten, Dr., 109, 152 

Lewis, Dr. P. H., 127, 391, 462, 466. 
470, 471,509,534 

Lind, Dr., 440, 447 
Liver, lesions of, 

periodical fever in, 372 

typhoid fever, 103 

typhus fever, 233 

yellow fever, 4S4 
Localities of periodical fever, 3S6— - 

Africa, 388 

Hungary, 388 

Italy, 389 

New England, 386 

United States, 386 

Upper Canada, 387 
Localities of typhoid fever, 107 — 1 IE 

Alabama, 109, 117 

Birmingham, 113 

Dedham, 117 

Edinburgh, 112 

France, 1 11 

Georgia, 110 

Germany, 111 

Gibraltar, 111 

Glasgow, 1 13 

Great Britain, 112 

Lowell, 57, 107, 114, 119 

Middle and Western States. 

Minorca, 113 

Mississippi, 1 10 

Missouri, 1 10 

Newcastle-upon-Tyne, 113 

New England, 51, 112 

New Orleans, 111 

New York, US 

Pennsylvania, 111 

Petit-Genes, 123 

Richmond, Mass., 119, 124 

Tennessee, 109 

Virginia, 1 1 1 
Localities of typhus fever, 23^— 24 1 

Cities of the United States, 238 

France, 240 

Germany, 241 

Great Britain, 241 

Ireland, 241 

Middle States, 240 

New England, 238, 240 

New York, 239 

Philadelphia, 198, 291 

Rheims, 299 

West Indies, 241 
Localities of yellow fever, 495 — 499 

Commercial cities, 495 

Gulf of Mexico, 496 

Infected districts, 498 



590 



INDEX. 



Localities of yellow fever — continued. 

Latitudes, 495 

Shipboard, 497 

Spain, 496 

United States, 496 

West Indies, 499 
Local bleeding, 

periodical fever in, 430 

typhoid fever, 182, 185 

typhus fever, 327 

yellow fever, 556 
Local pains, 

bilious fever in, 358 

typhoid fever, 64 

typhus fever, 206 

yellow fever, 469 
Lombard, Dr., 289 
Louis, 73, 79, 179, 191, 472, 579 
Louis and Trousseau, 460, 461, 477, 480, 

484 
Lungs, lesions of, 

periodical fever in, 367 

typhoid fever, 87 

typhus fever, 227 

yeilow fever, 477 
Luzenburg, Dr., 579 
Lymphatic glands, lesions of, 

periodical fever in, 380 

typhoid fever, 101 

typhus fever, 233 
Lyne, Dr., 258 

Macbride, Dr., 286 

Macculloch, Dr., 159, 448 

Maillot, 371,400—403, 423, 437, 449 

Malaria, 393, 502 

Mamellonation, 92, 232, 234,-480 

March, 

periodical fever of, 408 

typhoid fever, 135 

yellow fever, 533 
Marsh miasm, 393, 512 
Marsh, Sir H., 246 
Mateer, Dr., 253, 265 
Mattingly, Dr., 108, 126 
Mental anxiety in typhus fever, 267 
Mercurials, 

bilious fever in, 431 

congestive fever, 434 

typhoid fever, 168, 171,173 

typhus fever, 328 

yellow fever, 553 — 555, 558 
Mesenteric glands, lesions of bilious fever 
in, 380 

typhoid fever, 101 

typhus fever, 233 

yellow fever, 491 
Meteorism, 

periodical fever in, 363 

typhoid fever, 77, 142 

typhus fever, 215 

treatment of, 181 
Mettauer, Dr., Ill 
Miasmata, 393, 512 
Mills, Dr., 338 

bilious fever in, 358 



Mind, state of, 

congestive fever, 401 

periodical fever after, 413 

typhoid fever in, 65 

typhus fever, 207 

yellow fever, 470 
Mobile treatment of yellow fever, 559 
Mode of access, 

bilious fever in, 350 

congestive fever, 399 

typhoid fever, 56, 139 

typhus fever, 200 

yellow fever, 458 
Monette, Dr., 523 
Monomania, 67 

Morphia in congestive fever, 434. 435 
Mortality, 

congestive fever in, 416 

periodical fever, 415 

typhoid fever, 139 

typhus fever, 241, 264 

yellow fever, 541 „. 
Mosely, Dr., 413,566 
Mouth and tongue, 

bilious fever in, 361 

typhoid fever, 72 

typhus fever, 213 

yellow fever, 
M'William, Dr., 450 
Muscles, state of, 

bilious fever in, 360 

typhoid fever, 69 

typhus fever, 212 

yellow fever, 491 
Muscular debility, 

bilious fever in, 360 

typhoid fever, 69 

typhus fever, 212 

yellow fever, 473 
Music in yellow fever, 561 
Musk in typhoid fever, 177 

Names, 

bilious fever of, 349 

periodical fever, 347 

typhoid, fever, 50 

typhus fever, 199 

yellow fever, 457 
Nausea and vomiting, 

bilious fever in, 363 

congestive fever, 404 

typhoid fever, 73 

typhus fever, 214 

yellow fever, 466 
Nervous fever, 50 
Nervous symptoms, 

bilious fever in, 358 — 360 

typhoid fever, 63 — 71 

typhus fever, 206—213 

yellow fever, 469 — 474 
Neuralgia, 413 
New England fever, 51 
New Orleans Med. Jour., 579 
North, Dr., 239 
Nott, Dr., 481, 482, 487, 49S 



INDEX. 



591 



O'Brien, Dr., 198,224 
Occupation, as cause of, 

typhoid fever, 127 

yellow fever, 506 
Odor of body, 

typhoid fever in, 61 

typhus fever, 203 
Oesophagus, state of, 

typhoid fever in, 90 

yellow fever, 484 
O'Halloran, Dr., 487, 576 
Opium, 

congestive fever in, 434, 435 

intermittent fever, 440 

typhoid fever, 173, 178, 181 

typhus fever, 332 

Pains in the abdomen, 

bilious fever in, 363 

typhoid fever, 76 

typhus fever, 216 

yellow fever, 467 
Pains in back and limbs, 

bilious fever in, 358 

typhoid fever, 64 

typhus fever, 206 

yellow fever, 469 
Pancreas, lesions of, 103 
Parallel between typhus and typhoid fever, 

308 
Parry, Dr. Chas., 399, 404, 434 
Pennock, Dr., 198, 226, 292 
Percival, Dr. E., 198, 252, 260, 341 
Perforation of intestine, 

typhoid fever in, 77, 95, 136 

treatment of, 178, 181 
Periodical fever, 347 — 453 
Period of access, 

periodical fever in, 353 

yellow fever, 458 
Periodicity, 427, 428 
Peritonitis in typhoid fever, 136 
Perrine, Dr., 438 
Perry, Dr., 246, 252, 295 
Petechia?, 219, 236, 268 
Peyer's glands, lesions of, 

bilious fever in, 380 

constancy of, 152 — 158 

nature, 161 — 165 

typhoid fever in, 93 

typhus fever, 233, 235 

yellow fever, 48S 
Pharynx in typhoid fever, 90 
Physiognomy, 

bilious fever in, 360 

congestive fever, 402 

typhoid fever, 68, 141 

typhus fever, 210 

yellow fever, 471 
Physical signs, 

typhoid fever in, 63 

typhus fever, 204 

yellow fever, 476 
Pickels, Dr., 198, 207 
Plugging nostrils, 177 



Pneumonia, 

bilious fever in, 357 

typhoid fever, 88, 178 

typhus fever, 204 
Power, Dr., 306 
Prichard, Dr., 341 
Pringle, Sir J., 203, 220, 285, 337 
Prognosis, 

congestive fever in, 416 

periodical fever, 415 

typhoid fever, 139—146 

typhus fever, 268 

yellow fever, 541 — 546 
Prophylactics in yellow fever, 560 
Prost, 190 
Prostitutes, 506 
Pulse, 

bilious fever in, 357 

typhoid fever, 61, 139 

typhus fever, 203 

yellow fever, 461 
Pupil in typhus fever, 270 
Purgatives, 

bilious fever in, 431 

typhoid fever, 169, 1S3, 184 

typhus fever, 328 

yellow fever, 558 
Pym, Sir Wm., 576 

Quinine, sulphate of, 
bilious fever in, 432 
congestive fever, 434, 436, 437, 438, 

439 
intermittent fever, 439 
typhoid fever, 181 
typhus fever, 330 
yellow fever, 560 

Race, influence of, 

periodical fever on, 391 

typhoid fever, 126, 145 

yellow fever, 504, 544 
Recency of residence, 

typhoid fever, 127, 144 

typhus fever, 254 

yellow fever, 506 
Refrigerants, 

bilious fever in, 433 

typhoid fever, 173 
Reid/Dr., 112, 226,227, 228, 230. 231, 234 
Relapses, 

periodical fever in, 411, 442 

typhoid fever, 137 

typhus fever, 263 

yellow fever, 540 
Relations of lesions to symptoms, 

periodical fever in, 3S3 

typhoid fever, 105 

typhus fever, 236 

yellow fever, 491 
Remissions in periodical fever, 352 
Remittent fever, 350 — 414 
Respiration, 

congestive fever in, 406 

typhoid fever, 62, 140 

typhus fever, 204 



592 



INDEX. 



Respiration — continued. 

yellow fever, 476 
Restlessness, 

congestive fever in, 405 

yellow fever, 470 
Retention of urine, 

typhoid fever in, 143 

typhus fever, 218 

yellow fever, 468 
Rhonchi, 

bilious fever in, 357 

typhoid fever, 63 

typhus fever, 204 

yellow fever, 476 
Richardson, Dr., 381 
Rigidity of muscles, 

typhoid fever in, 69, 141 
Rodney, yellow fever at, 579 
Rose-colored spots, 79, 275, 285, 308 
Rush, Dr., 45S, 462, 464, 569 
Rutty, Dr., 243, 267 

Seaman, Dr., 520 
Season, influence of, 

periodical fever on, 389 

typhoid fever, 118, 119; 144 

typhus fever, 241 

yellow fever, 497, 52S 
Second attacks, 

periodical fever in, 411 

typhoid fever, 123 

typhus fever, 241 

yellow fever, 508 
Senac, 410, 446 
Senses, state of, 

bilious fever in, 360 

typhoid fever, 69 

typhus fever, 212 

yellow fever, 474 
Sensibility of skin, 

typhoid fever in, 69 

typhus fever, 212 
Septenary revolution, 355 
Sequelae, 

periodical fever of, 411, 442 

typhoid fever, 67, 138 

typhus fever, 262 

yellow fever, 540 
Sex, influence of, 

periodical fever, 391 

typhoid fever, 126 

typhus fever, 253, 266 

yellow fever, 502, 544 
Sexual appetite in yellow fever, 539 
Shapter, Dr., 453, 581 
Shattuck, Dr., 229, 230, 292 
Ships, 

typhus fever in, 239 

yellow fever, 496 
Sighing, 

congestive fever in, 405 

yellow fever, 476 
Signs, physical, 

typhoid fever in, 63 

typhus fever, 204 
Sims, Dr., 287 



Sinapisms, 

congestive fever in, 434 

typhus fever, 331 

yellow fever, 577 
Skin, state of, 

bilious fever in, 355 

congestive fever, 402 

typhoid fever, 59 

typhus fever, 202 

yellow fever, 460 
Sleep, 

typhus fever in, 210 

yellow fever, 471 
Small intestines, lesions of, 

bilious fever in, 380 

typhoid fever, 92 

yellow fever, 483 
Smith, Dr. N., 57, 60, 67, 78, 120, 171. 

192 
Smith, Dr. E. H., 519 
Smith, Dr. S., 280 
Softening of stomach, - 

periodical fever in, 378 

typhoid fever, 91 

typhus fever, 232 

yellow fever, 480 
Somnolence, 

typhoid fever in, 68, 140 

typhus fever, 210 
Sordes, 73, 464 

Spanish treatment of yellow fever, 55S 
Spleen, lesions of, 

periodical fever in, 378, 412 

typhoid fever, 102 

typhus fever, 233 

yellow fever, 491 
Sponging of body, 

typhoid fever in, 174, 175 

typhus fever, 329 
Sporadic cases of yellow fever, 511 
Spotted fever, 239 
Stages, 

periodical fever in, 352, 408 

typhoid fever, 135 

yellow fever, 536 
Stewardson, Dr., 373 
Stewart, Dr., 113, 216, 219, 259, 295 
Stille, Dr., 375 
Stimulants, 

congestive fever in, 433 — 439 

typhoid fever, 170, 176, 180 

typhus fever 329 

yellow fever, 558, 559 
Stomach, lesions of, 

periodical fever in, 378 

typhoid fever, 91 

typhus fever, 232 

yellow fever, 480 
Stomach, state of, 

congestive fever in, 404 

bilious fever, 363 

typhoid fever, 74 

typhus fever, 214 

yellow fever, 466 
Stone, Dr., 507, 581 
Strength, prostration of, 



INDEX. 



593 



Strength, prostration of— continued. 

bilious fever in, 360 

typhoid fever, 70, 141 

typhus fever, 212, 268 

yellow fever, 473 
Subsultus tendinum, 

bilious fever in, 360 

typhoid fever, 69, 141 

typhus fever, 213 
Sudamina, 82 
Suffusion of eyes, 

typhus fever in, 210 

yellow fever, 472 
Suffusion of face, 

typhus fever in, 210 

yellow fever, 473 
Sutton, Dr., 109 
Swallowing difficult, 73 
Sweats, 

bilious fever in, 433 

congestive fever, 401 

typhoid fever, 60 
Swelled legs, 138 
Swett, Dr., 369, 375 

Symptoms of congestive fever, 399 — 405 
Symptoms of bilious fever, 350 — 366 

abdominal, 363 

access, 350 

appetite, 362 

bowels, 364 

chills, 351 

epigastric, 363 

headache, 358 

mind, 35S 

muscles, 360 

nausea and vomiting, 363 

pains in back and limbs, 35S 

physiognomy, 360 

pulse, 357 

remissions, 352 

senses, 360 

skin, 355 

thirst, 362 

thoracic, 357 

tongue, 361 

type, 352 

urine, 365 
Symptoms of typhoid fever, 56 — 83 

abdominal pains, 76 

appetite and thirst, 73 

chills, 58 

cough, 63 

cutaneous eruptions, 79 

delirium, 65 

emaciation, 78 

epistaxis 79 

eschars, S2 

headache, 64 

mode of access, 56 

nausea and vomiting, 73 

pains in the back and limbs, 64 

physical signs, 63 

physiognomy, 68 

pulse, 61 

respiration, 62 

senses, 69 

38 



Symptoms of typhoid fever — continued. 

state of skin, 59 

state of mind, 65 

state of muscles, 69 

state of bowels, 74 

somnolence, 68 

tongue and mouth, 72 

tympanites, 77 

urine, 78 

vigilance, 68 
Symptoms of typhus fever, 200 — 225 

appetite, 214 

bowels, 215 

blood, 224 

chills, 201 

cutaneous eruptions, 2 1 S 

emaciation, 217 

epistaxis, 218 

eschars, 224 

headache, 206 

mind, 207 

mode of access, 200 

muscles, 212 

nausea and vomiting, 214 

pain in back and limbs, 206 

physiognomy, 210 

pulse, 203 

senses, 212 

skin, 202 

thoracic, 204 

tongue and mouth, 213 

urine, 217 
Symptoms of yellow fever, 45S — 476 

abdomen, 467 

appetite, 464 

bowels. 467 

chills, -160 

color of skin, 474 

epigastrium. 467 

headache, 469 

heat of skin, 460 

hemorrhages, 475 

local pains, 469 

mind, 470 

mode of access, 45S 

muscles, 473 

nausea and vomiting, 466 

period of access, 45S 

physiognomy, 471 

pulse, 461 

senses, 474 

skin, 460 

strength, 473 

thirst, 464 

thoracic, 476 

tongue and mouth, 4C4 

urine, 46S 

vomiting, 466 

Taste, sense of, 

typhoid fever in, 69 

yellow fever, 464 
Temperature of surface. 

bilious fever in, 366 

congestive fever. 

typhoid fever, 59 



594 



INDEX. 



Temperature of surface — continued. 

typhus fever, 202, 270 

yellow fever, 460 
Theory, 

periodical fever, of, 425 

typhoid fever, 159 — 166 

typhus fever, 322 

yellow fever, 550 
Thirst, 

bilious fever in, 362 

congestive fever, 404 

typhoid fever, 73 

typhus fever, 204 

yellow fever, 464 
Thoracic symptoms, 

bilious fever in, 357 

typhoid fever, 62 

typhus fever, 204 

yellow fever, 476 
Tinnitus aurium, 

bilious fever in, 360 

typhoid fever, 69 

typhus fever, 212 

yellow fever, 474 
Tongue and mouth, 

bilious fever in, 361 

typhoid fever, 72, 141 

typhus fever, 213, 269 

yellow fever, 464 
Tonics, 

typhoid fever in, 173, 176, 180 

typhus fever, 329 

yellow fever, 558 
Treatment of bilious fever, 429—433 

bloodletting, 429 

cinchona, 431 

diaphoretics, 433 

local bleeding, 430 

purgatives, 431 

refrigerants, 433 

sulphate of quinine, 432 
Treatment of congestive fever, 433—439 

bleeding, 435 

camphor, 434 

capsicum, 434 • 

cold dash, 435 

heat, 434 

opium, 434 

stimuli, 434 

sulphate of quinine, 434 
Treatment of intermittent fever, 439 
Treatment of typhoid fever, 167 — 187 

Bouillaud's method, 182 

Chomel's method, 174 

De Laroque's method, 183 

Dr. Jackson's method, 168 

Louis's method, 179 

miscellaneous, 184 

Dr. N. Smith's method, 171 
Treatment of typhus fever, 324 — 334 

affusions and ablutions, 328 

bleeding, 324 

camphor, 332 

diet, 334 

miscellaneous, 331 

opium, 332 



Treatment of typhus fever — continued. 

purgatives, 328 

stimulants and tonics, 329 

wine, 329 
Treatment of yellow fever, 552 — 562 

antiphlogistic, 555 

bloodletting, 555 

cinchona, 558 

cold affusion, 557 

conclusion, 561 t 

mercurials, 553, 556 

Mobile method, 559 

preliminary, 552 

prophylactics, 560 

purgatives, 558 
Spanish method, 558 

stimulants, 558 

tonics, 558 
Trotter, Dr., 337 
Tweedie, Dr., 283, 343 
Twitching of tendons, 

bilious fever in, 360 

typhoid fever, 69, 141 

typhus fever, 213 
Type of periodical fever, 352—355, 399 

yellow fever of, 533 
Tympanites, 77, 363 
Typhoid fever, 49, 194 
Typhoid entero-mesenteritis, 50 
Typhoid state, 156 
Typhus fever, 197—344 

Ulceration, 

epiglottis of, 89 

isolated follicles, 99, 100 

Peyer's glands, 94 

stomach, 91 
Unity of disease, 533 
Urinary organs, lesions of, 

periodical fever in, 383 

typhoid fever, 103 

typhus fever, 235 

yellow fever, 491 
Urine, retention of, 

typhoid fever in, 143 

typhus fever, 217 

yellow fever, 468 
Urine, state of, 

bilious fever in, 365 

typhoid fever, 78 

typhus fever, 217 

yellow fever, 468 

Varieties of congestive fever, 400 — 405 

algid, 402 

comatose, 400 

delirious, 401 

gastro-enteritic, 404 
Varieties of periodical fever, 397 — 407 
Varieties of typhoid fever, 129 — 133 

adynamic, 132 

ataxic, 132 

bilious, 132 

inflammatory, 132 

latent, 130 

mucous, 132 



INDEX. 



595 



Varieties of typhus fever, 255 
Varieties of yellow fever, 

congestive, 474, 530, 531 

inflammatory, 474, 530, 531 

mild, 529 

places, in different, 528 

remittent, 534, 535 *%» 

seasons, 528 
Vaughan, Dr., 284 
Vegetable decomposition, 393, 513 
Vigilance, 

typhoid fever in, 68 
Vision, state of, 

typhoid fever in, 69 

typhus fever, 212 

yellow fever, 474 
Vomiting, 

bilious fever in, 363 

typhoid fever, 73 

typhus fever, 214 

yellow fever, 466 
Vomit, black, 466 



Walcheren fever, 349 

Walking cases of yellow fever, 473, 53d 

Ware, Dr., 54 

Washington, yellow fever at, 523 

Weather, influence of, 

periodical fever on, 3S9 

typhoid fever, 144 

typhus fever, 243 

yellow fever, 500 
Wharton, Dr., 434 
Willan,Dr.,287 
Wilson, Dr. J., 472, 531,577 
Wine, 

typhoid fever, 171, 177 

typhus fever, 329 
Woodville, yellow fever at, 507, 512, 580 
Wooten, Dr., 109, 117, 152, 395 

Yellow fever, 457—581 

Yellowness of skin, 

bilious fever in, 356 

typhus fever, 257 

yellow fever, 474, 491, 493 



THE END 



JUL.Y, 1S52. 



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When the. postage is not thus paid in advance, it will be at double these rates. 
The Medical News and Library pays postage as a newspaper. Each number weighs between 
one and two ounces. Subscribers will therefore, under the new postage law, pay in advance for 
each quarter as follows : — 

For anv. distance under 50 miles, - 1£ cents per quarter. 

« " between 50 and 300 miles, - 2£ " " 

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BLANCHARD AND LEA'S PUBLICATIONS. 



NEW AND ENLARGED EDITION OF 

NEILL & SMITH'S CO Mj*E N Dl U M-(N OW READY.) 

AN ANALYTICAL COMPENDIUM 

OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE, 

FOR THE USE AND EXAMINATION OF STUDENTS. 
BY JOHN NEILL, M. D., 

Surgeon to the Pennsylvania Hospital ; Demonstrator of Anatomy in the University of Pennsylvania. 

AND 

FRANCIS GURNEY SMITH, M. D., 

Professor of Institutes of Medicine in the Pennsylvania Medical College. 
Second Edition, Revised and Improved. 
In one very large and handsomely printed volume, royal 12mo., of over 1000 large pages, with 
about 350 illustrations, strongly bound in leather, with raised bands. 
PREFACE TO THE NEW EDITION. 
The speedy sale of a large impression of this work has afforded to the authors gratifying evi- 
dence of the correctness of the views which actuated them in its preparation. In meeting the 
demand for a second edition, they have therefore been desirous to render it more worthy of the 
favor with which it has been received. To accomplish this, they have spared neither time nor 
labor in embodying in it such discoveries and improvements as have been made since its first ap- 
pearance, and such alterations as have been suggested by its practical use in the class and exami- 
nation-room. Considerable modifications have thus been introduced throughout all the depart- 
ments treated of in the volume, but more especially in the portion devoted to the " Practice of 
Medicine," which has been entirely rearranged and rewritten. The authors therefore again 
submit their work to the profession, with the hope that their efforts may tend, however humbly, 
to advance the great cause of medical education. 

Notwithstanding the increased size and improved execution of this work, the price has not been 
increased, and it is confidently presented as one of the cheapest volumes now before the profession. 



COOPER'S SURGICAL LECTURES— (Now Ready.) 
LECTURES ON THE 

PRINCIPLES AND PRACTICE OF SURGERY. 

BY BRANSBY B. COOPER, F. R. S., 

Senior Surgeon to Guy's Hospital. 
In one very large octavo volume, of seven hundred and fifty pages. 

For twenty-five years Mr. Bransby Cooper has been surgeon to Guy's Hospital ; and the volume before us 
may be said to consist of an account of the results of his surgical experience during that long period. 

We cordially recommend Mr. Bransby Cooper's Lectures as a most valuable addition to our surgical 
literature, and one which cannot fail to be of service both to students and to those who are actively engaged 
in the practice of their profession.— The Lancet. 

A good book by a good man is always welcome; and Mr. Bransby Cooper's book does no discredit to its 
paternity. It has reminded us, in its easy style and copious detail, more of Watson's Lectures, than any 
book we have seen lately, and we should not be surprised to see it occupy a similar position to that well- 
known work in professional estimation. It consists of seventy-five lectures on the most important surgical 
diseases. To analyze such a work is impossible, while so interesting is every lecture, that we feel ourselves 
really at a loss what to select for quotation. 

The work is one which cannot fail to become a favorite with the profession ; and it promises to supply a 
hiatus which the student of surgery has often to deplore.— Medical Times. 



MALGAIGNE'S SURGERY.— Now Ready. 

OPERATIVE SURGERY, 

BASED ON NORMAL AND PATHOLOGICAL ANATOMY. 

BY J. F. MALGrAIGNE. 

TRANSLATED FROM THE FRENCH, 

BY FREDERICK BRITTAN, A. B. 7 M.D., M.R.C.S.L. 

WITH NUMEROUS ILLUSTRATIONS ON WOOD. 
In one handsome octavo volume of nearly 600 pages. 

This work has, during its passage through the columns of the " Medical News and Library'> 
in 1850 and 1851, received the unanimous approbation of the profession, and in presenting it in 
a complete form the publishers confidently anticipate for it an extended circulation. 

Certainly one of the best books published on operative surgery. — Edinburgh Med. Journal. 

We can strongly recommend it both to practitioners and students, not only as a safe guide in the dissect- 
ing-room or operating-theatre, but also as a concise work of reference for all that relates to operative sur- 
gery. — Forbes's Review. 

Dr. Brittan has performed his task of translator and editor with much judgment. The descriptions are 
perfectly clear and explicit; and the author's occasional omissions of important operations proposed by 
British surgeons are judiciously supplied in brief notes. — Medical Gazette. 



6 BLANCHARD & LEA'S PUBLICATIONS.— (Surgery.) 

GROSS ON URINARY ORGANS— (Just Issued.) 
A PRACTICAL TREATISE ON THE 

DISEASES AND INJURIES OF THE URINARY ORGANS. 

BY S. D. GROSS, M. D., &., 

Professor of Surgery in the New York University. 
In one large and beautifully printed octavo volume, of over seven hundred pages. 
With numerous Illustrations. 
The author of this work has devoted several years to its preparation, and has endeavored t© 
render it complete and thorough on all points connected with the important subject to which it is 
devoted. It contains a large number of original illustrations, presenting the natural and patholo- 
gical anatomy of the parts under consideration, instruments, modes of operation, &c. &c, and in 
mechanical execution it is one of the handsomest volumes yet issued from the American press. 

Dr. Gross has brought all his learning, experience, tact, and judgment to the task, and has produce.d a 
work worthy of his high reputation. We feel perfectly safe in recommending it to our readers as a mono- 
graph unequalled in interest and practical value by any other on the subject in our language ; and we can- 
not help saying that we esteem it a matter of just pride, that another work so credilable to our country has 
been contributed to our medical literature by a Western physician.— The Western Journal of Medicine and 
Surgery. 

We regret that our limits preclude such a notice as this valuable contribution to our American medical 
literature merits. We have only room to say that the author deserves the thanks of the profession for this 
elaborate production; which cannot fail to augment the exalted reputation acquired by his former works 
for which he has been honored at home and abroad.— N. Y. Med. Gazette. 



COOPER ON DISLOCATIONS.— New Edition— (Just Issued.) 
A TREATISE ON 

DISLOCATIONS AND FRACTOBES OF THE JOINTS, 

By Sir ASTLEY P. COOPER, Bart., F.R.S.,&c. 

Edited by BEANSBY B. COOPER, F. R. S., &c. 

WITH ADDITIONAL OBSERVATIONS BY PROF. J. C. WARREN. 

A NEW AMERICAN EDITION, 

In one handsome octavo volume, with numerous illustrations on wood. 
After the flat of the profession, it would be absurd in us to eulogize Sir Astley Cooper's work on Disloca- 
tions. It is a national one, and will probably subsist as long as English Surgery. — Medico-Chirurg. Review. 



WORKS BY THE SAME AUTHOR. 

COOPER (SIR ASTLEY) ON THE ANATOMY AND TREATMENT OF ABDOMINAL HERNIA. 

1 lar°-e vol., imp. 8vo., with over 130 lithographic figures. 
COOPER ON THE STRUCTURE AND DISEASES OF THE TESTIS, AND ON THE THYMUS 

GLAND. 1 vol., imp. 8vo., with 177 figures on 29 plates. 
COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, WITH TWENTY-FIVE 

MISCELLANEOUS AND SURGICAL PAPERS. 1 large vol., imp. Svo., with 252 figures on 36 plates. 

These three volumes complete the surgical writings of Sir Astley Cooper. They are very handsomely 
printed, with a large number of lithographic plates, executed in the best style, and are presented at exceed- 
ingly low priees. 

ImIBTON & MUTTERS ST7RGHR3T. 

LECTURES ON THE OPERATIONS OF SURGERY, 

AND ON DISEASES AND ACCIDENTS REQUIRING OPERATIONS, 

BY ROBERT LISTON, Esq., F. R. S., &c. 

EDITED, WITH NUMEROUS ADDITIONS AND ALTERATIONS, 

BY T. D. MUTTER, M. D., 

Professor of Surgery in the Jefferson Medical College of Philadelphia. 
In one large and handsome octavo volume of 566 pages, with 216 wood-cuts. 

STANLEY ON THE BONES.— A Treatise on Diseases of the Bones. In one vol. 8vo., extra cloth. 286 pp. 
BRODIE'S SURGICAL LECTURES.— Clinical Lectures on Surgery. 1 vol. 8vo., cloth. 350 pp. 
BRODIE ON THE JOINTS.— Pathological and Surgical Observations on the Diseases of the Joints. 1 vol. 

BRODIE ON URINARY ORGANS.— Lectures on the Diseases of the Urinary Organs. 1 vol. 8vo., cloth. 

214 pp. 

*** These three works may be had neatly bound together, forming a large volume of" Brodie's 
Surgical Works." 780 pp. 
RICORD ON VENEREAL.— A Practical Treatise on Venereal Diseases. With a Therapeutical Summary 

and Special Formulary. Translated by Sidney Doane, M. D. Fourth edition. 1 vol. Svo. 340 pp. 
DURLACHER ON CORNS, BUNIONS. &c— A Treatise on Corns, Bunions, the Diseases of Nails, and 

the General Managementof the Feet. In one 12mo. volume, cloth. 134 pp. 
GUTHRIE ON THE BLADDER, &c— The Anatomy of the Bladder and Urethra, and the Treatment of the 

Obstructions to which those Passages are liable. In one vol. 8vo. 150 pp. 
LAWRENCE ON RUPTURES.— A Treatise on Ruptures, from the fifth London Edition. In one Svo. vol. 

sheep. 4S0 pp. 



BLANCHARD & LEA'S PUBLICATIONS.— (Surgery.) 7 

LIBRARY OF SURGICAL KNOWLEDGE. 

A SYSTEM OF SURGERY. 

BY J. M. CHELIUS. 

TRANSLATED FROxM THE GERMAN, 
AND ACCOMPANIED WITH ADDITIONAL NOTES AND REFERENCES, 

BY JOHN F. SOUTH. 

Complete in three very large octavo volumes of nearly 2200 pages, strongly bound, with raised 

bands and double titles. 

We do not hesitate to pronounce it the best and most comprehensive system of modern surgery with 
which we are acquainted. — Medico- Chirurgical Review. 

The fullest and ablest digest extant of all that relates to the present advanced state of Surgical Pathology.— 
American Medical Journal. 

If we were confined to a single work on Surgery, that work should be Chelius's. — St. Louis Med. Journal. 

As complete as any system of Surgery can well be. — Southern Medical and Surgical Journal. 

The most finished system of Surgery in the English language. — Western Lancet. 

The mo*t learned and complete systematic treatise now extant. — Edinburgh Medical Journal. 

No work in the English language comprises so large an amount of information relative to operative medi- 
cine and surgical pathology. — Medical Gazette. 

A complete encyclopedia of surgical science— a very complete surgical library— by far the most complete 
and scientific system of surgery in the English language.— N. Y. Journal of Medicine. 

One of the most complete treatises on Surgery in the English language — Monthly Journal of Med. Science. 

The most extensive and comprehensive account of the art and science of Surgery in our language. — Lancet. 



A TREATISE ON THE DISEASES OF THE EYE. 

BY W. LAWRENCE, F.R.S. 

A new Edition. With many Modifications and Additions, and the introduction of nearly 200 Illustrations, 

BY ISAAC HAYS, M.D. 
In one very large 8vo. vol. of S60 pages, with plates and wood-cuts through the text. 



JONES ON THE EYE. 

THE PRINCIPLES AND PRACTICE 

OF OPHTHALMIC MEDICINE AND SURGERY. 

BY T. WHARTON JONES, F. R. S., &c. &c. 
EDITED BY ISAAC HAYS, M.D., &c. 

In one very neat volume, large royal 12mo. of 529 pages, with four plates, plain or colored, and 
ninety-eight well executed wood-cuts. 



A NEW TEXT-BOOK ON SURGERY— (Now Ready.) 

THE PRINCIPLES AND "PRACTICE OF SURGERY. 

BY WILLIAM PIRRIE, F.R.S.E., 

Regius Professor of Surgery in the University of Aberdeen. 

Edited by JOHN NEILL, M. D., 

Demonstrator of Anatomy in the University of Pennsylvania. Lecturer on Anatomy in the Medical 
Institute of Philadelphia, &c. 

In one very handsome octavo volume, of 780 pages, with 316 illustrations. 
The object of the author, in the preparation of this volume, has been to present to the student a 
complete text-book of surgery, embracing both the principles and the practice in their mutual rela- 
tions, according to the latest state of scientific development. In accomplishing this, his aim has been 
to combine simplicity of arrangement, and conciseness and clearness oi description, with the eluci- 
dation of sound principles and the modes of practice which his own experience and the teachings of 
the best authorities have shown to be the most successful. The Editor has, therefore, found but 
little to add respecting European surgery, and his efforts consequently have been directed towards 
introducing such improvements as have been pointed out by the practitioners of the United States, 
and such further information as may be requisite for the guidance of the student in this country. — 
Of the very numerous illustrations, the greater portion are from preparations in the authors mu- 
seum, or from patients under his care. These have been reproduced with great care, and the 
whole is presented as an original and highly practical work, and at the same time as a handsome 
specimen of typographical execution. 

MAURY'S DENTAL SURGERY.— A Treatise on the Dental Art. founded on Actual Experience. Illus- 
trated by 241 lithographic figures and 54 wood-cuts. Translated by J. B. Savier. In 1 Svo. vol., sheep. 296 pp. 

DUFTON ON THE EAR— The Nature and Treatment of Deafness and Diseases of the Ear;' and the Treat- 
ment of the Deaf and Dumb. One small 12mo. volume. 120 pp. 

SMITH ON FRACTURES— A Treatise on Fractures in the vicinity of Joints, and on Dislocations. One 
vol. 8vo., with 200 beautiful wood-cuts. 



8 BLANCHARD & LEA'S PUBLICATIONS.— (Surgery.) 

NEW AND IMPORTANT WORK ON PRACTICAL SURGERY.— (JUST ISSUED,) 

OPERATIVE SURGERY. 

BY FREDERICK C. SKBY, F. R. S., &c. 

In one very handsome octavo volume of over 650 pages, with about one hundred wood-cuts. 

The object of the author, in the preparation of this work, has been not merely to furnish the 
student with a guide to the actual processes of operation, embracing the practical rules required 
to justify an appeal to the knife, but also to present a manual embodying such principles as might 
render it a permanent work of reference to the practitioner of operative surgery, who seeks to 
uphold the character of his profession as a science as well as an art. In its composition he has 
relied mainly on his own experience, acquired during many years' service at one of the largest of 
the London hospitals, and has rarely appealed to other authorities, except so far as personal inter- 
course and a general acquaintance with the most eminent members of the surgical profession 
have induced him to quote their opinions. 

From Professor C. B. Gibson, Richmond, Virginia. 

I have examined the work with some care, and am delighted with it. The style is admirable, the matter 
excellent, and much of it original and deeply interesting, whilst the illustrations are numerous and better 
executed than those of any similar work I possess. 

In conclusion we must express our unqualified praise of the work as a whole. The high moral tone, the 
liberal views, and the sound information which pervades it throughout, reflect the highest credit upon the 
talented author. We know of no one who has succeeded, whilst supporting operative surgery in its proper 
rank, in promulgating at the same lime sounder and more enlightened views upon that most important of 
all subjects, the principle that should guide us in having recourse to the knife.— Medical Times. 

The treatise is, indeed, one on operative surgery, but it is one in which the author throughout shows that 
he is most anxious to place operative surgery in its just position. He has acted as a judicious, but not 
partial friend; and while he shows throughout that he is able and ready to perform any operation which the 
exigencies and casualties of the human frame may require, he is most cautious in specifying the circum- 
stances which in each case indicate and contraindicate operation. It is indeed gratifying to perceive the 
sound and correct views which Mr. Skey entertains on the subject of operations in general, and the gentle- 
manly tone in which he impresses on readers the lessons which he is desirous to inculcate. His work is a 
perfect model for the operating surgeon, who will learn from it not only when and how to operate, but some 
more noble and exalted lessons which cannot fail to improve him as a moral and social agent.— Edinburgh 
Medical and Surgical Journal. 

THE STUDEN-PS TEXT-BOOK. 

THE PRINCIPLES AND PRACTICE OF MODERN SURGERY, 

BY ROBERT DRUITT, Fellow of the Royal College of Surgeons. 
A New American, from the last and improved London Edition, 

Edited by F. W. SARGENT, M.D., Author of "Minor Surgery," &c. 

ILLUSTRATED WITH ONE HUNDRED AND NINETY-THREE WOOD ENGRAVINGS. 

In one very handsomely printed octavo volume of 576 large pages. 
From Professor Brainard, of Chicago, Illinois. 
I think it the best work of its size, on that subject, in the language. 

From Professor Rivers, of Providence, Rhode Island. 
I have been acquainted with it since its first republication in this country, and the universal praise it has 
received I think well merited. 

From Professor May, of Washington, D. C. 
Permit me to express my satisfaction at the republication in so improved a form of this most valuable work. 
I believe it to be one of the very best text-books ever issued. 

From Professor McCoole, of Baltimore. 
I cannot withhold my approval of its merits, or the expression that no work is better suited to the wanis 
of the student. I shall commend it to my class, and make it my chief text-book. 



FERGUSSON'S OPERATIVE SURGERY. NEW EDITION. 

A SYSTEM OF PRACTICAL SURGERY, 

BY WILLIAM FERGUSSON, F. R. S. E., 

Professor of Surgery in King's College, London, &c. &c. 

THIRD AMERICAN, FROM THE LAST ENGLISH EDITION. 

"With 274 Illustrations. 

In one large and beautifully printed octavo volume of six hundred and thirty pages. 

It is with unfeigned satisfaction that we call the attention of the profession in this country to this excellent 

work. It richly deserves the reputation conceded to it, of being the best practical Surgery extant, at least in 

the English language.— Medical Examiner. 

A NEW MINOR SURGERY. 

ON BANDAGING AND OTHER POINTS OF MINOR SURGERY. 

BY F. W. SARGENT, M. D. 

In one handsome royal 12mo. volume of nearly 400 pages, with 128 wood-cuts. 
From Professor Gilbert, Philadelphia. 
Embracing the smaller details of surgery, which are illustrated by very accurate engravings, the work 
becomes one of very great importance to the practitioner in the performance of his daily duties, since sneli 
information is rarely found in the general works on surgery now in use. 



BLANCHARD & LEA'S PUBLICATIONS.— {Surgery.) 



THE GREAT ATLAS OF SURGICAL ANATOMY. 
(VOW COMPLETE.) 

suhgioal"anatomy. 

BY JOSEPH MACLISE, Surgeon. 

IN ONE VOLUME, VERY LARGE IMPERIAL QUARTO. 
"With Sixty-eight large and splendid Plates, drawn in the best style, and 

beautifully colored, 

Containing one hundred and ninety Figures, many of them the size of life. 

TOGETHER WITH COPIOUS EXPLANATORY LETTER-PRESS. 

Strongly and handsomely bound in extra cloth, being one of the best executed and cheapest surgi- 
cal works ever presented in this country. 

This great work being now complete, the publishers confidently present it to the attention of the 
profession as worthy in every respect of their approbation and patronage. No complete work 
of the kind has yet been published in the English language, and it therefore will supply a want 
long felt in this country of an accurate and comprehensive Atlas of Surgical Anatomy to which 
the student and practitioner can at all times refer, to ascertain the exact relative position of 
the various portions of the human frame towards each other and to the surface, as well as their 
abnormal deviations. The importance of such a work to the student in the absence of anato- 
mical material, and to the practitioner when about attempting an operation, is evident, while the 
price of the book, notwithstanding the large size, beauty, and finish of the very numerous illustra- 
tions, is so low as to place it within the reach of every member of the profession. The publishers 
therefore confidently anticipate a very extended circulation for this magnificent work. 

To present some idea of the scope of the volume, and of the manner in which its plan has been 
carried out, the publishers subjoin a very brief summary of the plates. 

Plates 1 and 2. — Form of the Thoracic Cavity and Position of the Lungs, Heart, and larger Blood- 
vessels. 

Plates 3 and 4. — Surgical Form of the Superficial Cervical and Facial Regions, and the Relative 
Positions of the principal Bloodvessels, Nerves, &c. 

Plates 5 and 6. — Surgical Form of the Deep Cervical and Facial Regions, and Relative Positions 
of the principal Bloodvessels, Nerves, &c. 

Plates 7 and 8. — Surgical Dissection of the Subclavian and Carotid Regions, and Relative Anatomy 
of their Contents. 

Plates 9 and 10. — Surgical Dissection of the Sterno-Clavicular or Tracheal Region, and Relative 
Position of its main Bloodvessels, Nerves, &c. 

Plates 11 and 12. — Surgical Dissection of the Axillary and Brachial Regions, displaying the Relative 
Order of their contained parts. 

Plates 13 andl4. — Surgical Form of the Male and Female Axillae compared. 

Plates 15 and 16. — Surgical Dissection of the Bend of the Elbow and the Forearm, showing the 
Relative Position of the Arteries, Veins, Nerves, &c. 

Plates 17, 18 and 19. — Surgical Dissections of the Wrist and Hand. 

Plates 20 and 21. — Relative Position of the Cranial, Nasal, Oral, and Pharyngeal Cavities, &c. 

Plate 22. — Relative Position of the Superficial Organs of the Thorax and Abdomen. 

Plate 23. — Relative Position of the Deeper Organs of the Thorax and those of the Abdomen. 

Plate 24. — Relations of the Principal Bloodvessels to the Viscera of the Thoracico-Abdominal 
Cavity. 

Plate 25. — Relations of the Principal Bloodvessels of the Thorax and Abdomen to the Osseous 
Skeleton, &c. 

Plate 26.— Relation of the Internal Parts to the External Surface of the Body. 

Plate 27. — Surgical Dissection of the Principal Bloodvessels, &c, of the Inguino-Femoral Region. 

Plates 28 and 29. — Surgical Dissection of the First, Second, Third, and Fourth Layers of the 
Inguinal Region, in connection with those of the Thigh. 

Plates 30 and 31. — The Surgical Dissection of the Fifth, Sixth, Seventh and Eighth Layers of the 
Inguinal Region, and their connection with those of the Thigh. 

Plates 32, 33 and 34. — The Dissection of the Oblique or External and the Director Internal Ingui- 
nal Hernia. 

Plates 35, 36, 37 and 3S. — The Distinctive Diagnosis between External and Internal Inguinal Hernia, 
the Taxis, the Seat of Stricture, and the Operation. 

Plates 39 and 40. — Demonstrations of the Nature of Congenital and Infantile Inguinal Hernia, and 
of Hydrocele. 

Plates 41 and 42. — Demonstrations of the Origin and Progress of Inguinal Hernia in general. 

Plates 43 and 44. — The Dissection of Femoral Hernia, and the Seat of Stricture. 

Plates 45 and 46. — Demonstrations of the Origin and Progress of Femoral Hernia, its Diagnosis, the 
Taxis, and the Operation. 

Plate 47. — The Surgical Dissection of the principal Bloodvessels and Nerves of the Iliac and Fe- 
moral Regions. 

Plates 48 and 49. — The Relative Anatomy of the Male Pelvic Organs. 

Plates 50 and 51. — The Surgical Dissection of the Superficial Structures of the Male Perineum. 

Plates 52 and 53. — The Surgical Dissection of the Deep Structures of the Male Perineum. — The 
Lateral Operation of Lithotomy. 



10 BLANCHARD & LEA'S PUBLICATION S.— (Surgery.) 

MACLISE' S SURGICAL ANATOMY— (Continued.) 

Plates 54, 55 and 56. — The Surgical Dissection of the Male Bladder and Urethra. — Lateral and 
Bilateral Lithotomy compared. 

Plates 57 and 58. — Congenital and Pathological Deformities of the Prepuce and Urethra. — Struc- 
ture and Mechanical Obstructions of the Urethra. 

Plates 59 and 60. — The various forms and positions of Strictures and other Obstructions of the 
Urethra. — False Passages. — Enlargements and Deformities of the Prostate. 

Plates 61 and 62. — Deformities of the Prostate. — Deformities and Obstructions of the Prostatic 
Urethra. 

Plates 63 and 64. — Deformities of the Urinary Bladder. — The Operations of Sounding for Stone, of 
Catheterism, and of Puncturing the Bladder above the Pubes. 

Plates 65 and 66. — The Surgical Dissection of the Popliteal Space, and the Posterior Crural Region. 

Plates 67 and 68. — The Surgical Dissection of the Anterior Crural Region, the Ankles, and the Foot. 

Notwithstanding the short time in which this work has been before the profes- 
sion, it has received the unanimous approbation of all who have examined it. From 
among a very large number of commendatory notices with which they have been 
favored, the publishers select the following : — 

From Prof. Kimball, Pittsfield, Mass. 
1 have examined these numbers with the greatest satisfaction, and feel bound to say that they are alto- 
gether the most perfect and satisfactory plates of the kind that I have ever seen. 

From Prof. Brainard, Chicago, III. 
The work is extremely well adapted to the use both of students and practitioners, being sufficiently exten- 
sive for practical purposes, without being so expensive as to place it beyond their reach. Such a work was 
a desideratum in this country, and I shall not fail to recommend it to those within the sphere of my acquaint- 
ance. 

From Prof. P. F. Eve, Augusta, Ga. 
I consider this work a great acquisition to my library, and shall take pleasure in recommending it on all 
suitable occasions. 

From Prof. Peaslee, Brunswick, Me. 
The second part more than fulfils the promise held out by the first, so far as the beauty of the illustrations 
is concerned ; and, perfecting my opinion of the value of the work, so far as it has advanced, I need add 
nothing to what I have previously expressed to you. 

From Prof. Gunn, Ann Arbor, Mich. 
The plates in your edition of Maclise answer, in an eminent degree, the purpose for which they are 
intended. I shall take pleasure in exhibiting it and recommending it to my class. 
From Prof. Rivers, Providence, R. I. 
The plates illustrative of Hernia are the most satisfactory I have ever met with. 

From Professor S. D. Gross, Louisville, Ky. 
The work, as far as it has progressed, is most admirable, and cannot fail, when completed, to form a most 
valuable contribution to the literature of our profession. It will afford me great pleasure to recommend it to 
the pupils of the University of Louisville. 

From Professor R. L. Howard, Columbus, Ohio. 
In all respects, the first number is the beginning of a most excellent work, filling completely what might 
be considered hitherto a vacuum in surgical literature. For myself, in behalf of the medical profession. I 
wish to express to you my thanks for this truly elegant and meritorious work. I am confident that it will 
meet with a ready and extensive sale. I have spoken of it in the highest terms to my class and my profes- 
sional brethren. 

From Prof C. B. Gibson, Richmond, Va. 
I consider Maclise very far superior, as to the drawings, to any work on Surgical Anatomy with which I 
am familiar, and I am particularly struck with the exceedingly low price at which it is sold. I cannot doubt 
that it will be extensively purchased by the profession. 

From Prof. Granville S. Pattison, New York. 

The profession, in my opinion, owe you many thanks for the publication of this beautiful work — a work 

which, in the correctness of its exhibitions of Surgical Anatomy, is not surpassed by any work with which 

I am acquainted; and the admirable manner in which the lithographic plates have been executed and 

colored is alike honorable to your house and to the arts in the United States. 

From Prof. J. F. May, Washington, D. C. 

Having examined the work, I am pleased to add my testimony to its correctness, and to its value as a 

work of reference by the surgeon. 

From Prof. Alden Marsh, Albany, N. Y. 
From what I have seen of it, I think the design and execution of the work admirable, and, at the proper 
time in my course of lectures, I shall exhibit it to the class, and give it a recommendation worthy of its great 
merit. 

From H. H. Smith, M. D., Philadelphia. 
Permit me to express my gratification at the execution of Maclise's Surgical Anatomy. The plates are, in 
my opinion, the best lithographs that I have seen of a medical character, and the coloring of this number 
cannot, I think, be improved. Estimating highly the contents of this work, I shall continue to recommend it 
to my class as I have heretofore done. 

From Prof. D. Gilbert, Philadelphia. 
Allow me to say, gentlemen, that the thanks of the profession at large, in this country, are due to you for 
the republication of this admirable work of Maclise. The precise relationship of the organs in the regions 
displayed is so perfect, that even those who have daily access to the dissecting-room may, by consulting 
this work, enliven and confirm their anatomical knowledge prior to an operation. But it is to the thousands 
of practitioners of our country who cannot enjoy these advantages that the perusal of those plates, with 
their concise and accurate descriptions, will prove of infinite value. These have supplied a desideratum, 
which will enable them to refresh their knowledge of the important structures involved in their surgical 
cases, thus establishing their self-confidence, and enabling them to undertake operative procedures with 
every assurance of success. And as all the practical departments in medicine rest upon the same basis, and 
are enriched from the same sources, I need hardly add that this work should be found in the library of every 
practitioner in the land. 



BLANCHARD & LEA'S PUBLICATIONS.— (Surgery.) 11 

MACLISE'S SURGICAL ANATOMY— (Continued.) 

From Professor J. M. Bush. Lezi?igton. Ky. 

1 am delighted with both the plan and execution of the work, and shall take all occasions to recommend .t 
to my private pupils and public classes. 

The most accurately engraved and beautifully colored plates we have ever seen in an American book- 
one of the best and cheapest surgical works ever published.— Buffalo Medical Journal. 

It is very rare that so elegantly printed, so well illustrated, and so useful a work, is offered at so moderate 
a price. — Charleston Medical Journal. 

A work which cannot but please the most fastidious lover of surgical science. In it. by a succession of 
plates, are brought to view the relative anatomy of the parts included in the important surgical divisions of 
the human body, with that fidelity and neatnes= of touch which is scarcely excelled by nature herself. While 
wt believe that nothing but an extensive circulation can compensate the publishers for tne outlay in the 
production of the work— furnished as it is at a very moderate price, within the reach of all— we desire to see 
it have that circulation which the zeal and peculiar skill of the author, the utility of the work, and the neat 
stvle with which it is executed, should demand for it in a liberal profession. — -V. Y. Jour, of Medicine. 

This is an admirable reprint of a deservedly popular London publication. Its plates can boast a superi- 
ority that places them almost beyond thereacli of competition. And we feel too thankful to the Philadel- 
phia publishers for their very handsome reproduction of the whole work, and at a rate within everybody's 
reach, not to urge all our medical friends to give it. for their own sakes, the cordial welcome it deserves, in 
a speedy and extensive circulation.— The MfJical Examiner. 

When the whole has been published it will be a complete and beautiful system of Surgical Anatomy, hav- 
ing an advantage which is important, and not possessed by colored plates generally, viz., it? cheapness, 
which places it within the reach of every one who may feel disposed to possess the work. Every practi- 
tioner, we think, should have a work of this kind within reach, as there are many operations requiringimme- 
diate performance in which a book of reference will prove most valuable. — Southern Med. and Surg. Jour-i. 

No such lithographic illustrations of surgical regions have hitherto, we think, been given. While the ope- 
rator is shown every vessel and nerve where an operation is contemplated, the exact anatomist is refreshed 
by those clear and distinct dissections which every one must appreciate who has a particle of enthusiasm. 
The English medical press has quite exhausted the words of praise in recommending this admirable treatise. 
Those who have any curiosity to gratify in reference to the perfectibility of the lithographic art in delinea- 
ting the complex mechanism of the human body, are invited to examine our copy. If anything will induce 
surgeons and students to patronize a book of such rare value and every-day importance to them, it will be a 
survey of the arlistical skill exhibited in these fac-similes of nature. — Boston Medical and Surg. Journal. 

These plates will form a valuable acquisition to practitioners spttled in the country, whether engaged 
in surgical, medical, or general practice. — Edinburgh Medical and Surgical Journal. 

We are well assured that there are none of the cheaper, and but few of the more expensive works on 
anatomy, which will form so complete a guide to the student or practitioner as these plates. To practitioners, 
in particular, we recommend this work as far better, and not at all more expensive, than the heterogeneous 
compilations most commonly in use, and which, whatever their value to the student preparing for examina- 
tion, are as likely to mislead as to guide the physician in physical examination, or the surgeon in the per- 
formance of an operation.— Monthly Journal of Mtdical Sen 

We know of no work on surgical anatomy which can compete with it. — Lancet. 

This is by far the ablest work on Surgical Anatomy that has come under our observation. We know of 
no other work that would justify a student, in any degree, for neglect of actual dissection. A careful study 
of these plates, and of the commentaries on them, would almost make an anatomistof a diligent student. And 
to one who has studied anatomy by dissection, this work is invaluable as a perpetual remembrancer, in mat- 
ters of knowledge that may slip from the memory. The practitioner can scarcely consider himself equipped 
for the duties of his profession without such a work as this, and this has no rival, in his library. In those 
sudden emergencies that so often arise, and which require the instantaneous command of minute anatomical 
knowledge, a work of this kind keeps the details of the dissecting-room perpetually fresh in the memory. 
We appeal to our readers, whether any one can justifiably undertake the practice of medicine who is not 
prepared to give all needful assistance, in all matters demanding immediate relief. 

We repeat that no medical library, however large, can be complete without Maclise's Surgical Anatomy. 
The American edition is well entitled to the confidence of the profession, and should command, among them, 
an extensive sale. The investment of the amount of the cost of this work will prove to be a very profitable 
one, and if practitioners would qualify themselves thoroughly with such important knowledge as is contained 
in works of this kind, there would be fewer of them sighing for employment. The medical profession should 
spring towards such an opportunity as is presented in this republication, to encourage frequent repetitions of 
American enterprise of this kind.— The Western Journal of Medicine and Surgery. 

MILLER'S PRINCIPLES OF SURGERY. 

NEW AND BEAUTIFULLY ILLUSTRATED EDITION— (Now Ready.) 

PRINCIPLES~OF SURGERY. 

BY JAMES MILLER, F. R. S. E., F.R.C. S.E., 

Professor of Surgery in the University of Edinburgh. 

THIRD AMERICAN, FROM THE SECOND AND ENLARGED EDINBURGH EDITION. 
Revised, with Additions, by F. W. SARGEXT, M.D., 

Author of M Minor Surgery,'' &c. 
In one very large and handsome octavo volume, of seven hundred and fifty-two pages, 

WITH ABOUT TWO HUNDRED AND FIFTY EXQUISITE WOOD ENGRAVINGS. 

The very extensive additions and alterations which the author has introduced into this edition 
have rendered it essentially a new work. By common consent, it has been pronounced the most 
complete and thorough exponent of the present state of the science of surgery in the English lan- 
guage, and the American publishers in the preparation of the present edition have endeavored to 
render it in all respects worthy of its extended reputation. The press has been carefully revised 
by the editor, who has introduced such notes and observations as the rapid progress of surgical 
investigation and pathology have rendered necessary. The illustrations, which are very numerous, 
and of a high order of merit, both artistic and practical, have been engraved with great care, and 
in every point of mechanical execution it is confidently presented as one of the most beautiful 
volumes as yet published in this country. 

BY THE SAME AUTHOR. 

THE PRACTICE OP SURGERY. 

In one octavo volume, of 496 pages. 



12 BLANCHARD & LEA'S PUBLICATIONS.— (Anatomy.) 

SHARPEY AND QUAIN'S ANATOMY.— Lately Issued. 

HUMAN ANATOMY.. 

BY JONES QUAIN, M.D. 

FROM THE FIFTH LONDON EDITION. 

EDITED BY 

RICHARD QUAIN, F. R. S., and WILLIAM SHARPEY, M. D. ; F. R. S., 

Professors of Anatomy and Physiology in University College, London. 
REVISED, WITH NOTES ASTI> ADDITIONS, 

BY JOSEPH LEIDY, M. D. 

Complete in Two large Octavo Volumes, of about Thirteen Hundred Pages. 
Beautifully Illustrated -with over Five Hundred Engravings on "Wood. 

We have here one of the best expositions of the present state of anatomical science extant. There is not 
probably a work to be found in the English language which contains so complete an account of the progress 
and present state of general and special anatomy as this. By the anatomist this work must be eagerly 
sought for, and no student's library can be complete without it.— The N. Y. Journal of Medicine. 

We know of no work which we would sooner see in the hands of every student of this branch of medical 
science than Sharpey and Quain's Anatomy.— The Western Journal of Medicine and Surgery. 

It may now be regarded as the most complete and best posted up work on anatomy in the language. It 
will be found particularly rich in general anatomy.— The Charleston Medical Journal. 

We believe we express the opinion of all who have examined these volumes, that there is no work supe- 
rior to them on the subject which they so ably describe. — Southern Medical and Surgical Journal. 

It is one of the most comprehensive and best works upon anatomy in the English language. It is equally 
valuable to the teacher, practitioner, and student in medicine, and to the surgeon in particular. — The Ohio 
Medical and Surgical Journal. 

To those who wish an extensive treatise on Anatomy, we recommend these handsome volumes as the best 
that have ever issued from the English or American Press.— The N. W. Medical and Surgical Journal. 

VVe believe that any country might safely be challenged to produce a treatise on anatomy so readable, so 
clear, and so full upon all-important topics. — British and Foreign Medico- Chirurgical Review. 

It is indeed a work calculated to make an era in anatomical study, by placing before the student every de* 
partment of his science, with a view to the relative importance of each ; and so skillfully have the different 
parts been interwoven, that no one who makes this work the basis of his studies will hereafter have any ex- 
cuse for neglecting or undervaluing any important particulars connected with the structure of the human 
frame; and whether the bias of his mind lead him in a more especial manner to surgery, physic, or physiolo- 
gy, he will find here a work at once so comprehensive and practical as to defend him from exclusiveness on 
the one hand, and pedantry on the other.— Monthly Journal and Retrospect of the Medical Sciences. 

We have no hesitation in recommending this treatise on anatomy as the most complete on that subject in 
the English language ; and the only one, perhaps, in any language, which brings the state of knowledge for- 
ward to the most recent discoveries. — The Edinburgh Medical and Surgical Journal. 

Admirably calculated to fulfil the object for which it is intended.— Provincial Medical Journal. 

The most complete Treatise on Anatomy in the English language.— Edinburgh Medical Journal. 

There is no work in the English language to be preferred to Dr. Quain's Elements of Anatomy. — London 
Journal of Medicine. 

THE STUDENT'S TEXT-BOOK OF ANATOMY. 
NEW AND IMPROVED EDITION — JUST ISSUED. 

A SYSTEM OF HUMAN ANATOMY, 

GENERAL AND SPECIAL. 

BY ERASMUS WILSON, M. D. 

FOURTH AMERICAN FROM THE LAST ENGLISH EDITION. 
EDITED BY PAUL B. GODDARD, A. M., M. D. 

WITH TWO HUNDRED AND FIFTY ILLUSTRATIONS. 

Beautifully printed, in one large octavo volume of nearly six hundred pages. 

In many, if not all the Colleges of the Union, it has become a standard text-book. This, of itself, is sufficiently 
expressive of its value. A work very desirable to the student ; one, the possession of which will greatly 
facilitate his progress in the study of Practical Anatomy. — New York Journal of Medicine. 

Its author ranks with the highest on Anatomy. — Southern Medical and Surgical Journal. 

It offers to the student all the assistance that can be expected from such a work. — Medical Examiner. 

The most complete and convenient manual for the student we possess. — American Journal of Med. Science. 

In every respect this work, as an anatomical guide for the student and practitioner, merits our warmest 
and most decided praise. — London Medical Gazette. 



SIBSON'S MEDICAL ANATOMY— (Preparing.) 

MEDICAL ANATOMY; 

Illustrating the Form, Structure, and Position of the Internal Organs in Health and Disease. 

BY FRANCIS SIBSON, M.D., F.R.S., 

Physician to St. Mary's Hospital. 
With numerous and beautiful colored Plates* 

In Imperial Quarto, to match " Ma'clise's Surgical Anatomy." 



BLANCHARD &, LEA'S PUBLICATIONS— (Anatomy.) 13 

HORNER'S ANATOMY. 
MUCH IJtlPKOYED JMJVJJ EJVLJIIIGEI} EVlTIOlW—iJust Issued,) 

SPECIAL ANATOMY AND HISTOLOGY. 

BY WILLIAM E. HORNER, M. D., 

Professor of Anatomy in the University of Pennsylvania. &c. 

EIGHTH EDITION'. 
EXTENSIVELY REVISED AND MODIFIED TO 1851. 

In two large octavo volumes, handsomely printed, with several hundred illustrations. 

This work has enjoyed a thorough and laborious revision on the part of the author, with the 
view of bringing it fully up to the existing state of knowledge on the subject of general and special 
anatomy. To adapt it more perfectly to the wants of the student, he has introduced a large number 
of additional wood engravings, illustrative of the objects described, while the publishers have en- 
deavored to render the mechanical execution of the work worthy of the extended reputation which 
it has acquired. The demand which has carried it to an EIGHTH EDITION is a sufficient evidence 
of the value of the work, and of its adaptation to the wants of the student and professional reader. 



NEW AND CHEAPER EDITION OF 
SJfMITH Sf HORJTEWS JUTJlTOJIIVJll, JlTL*lS. 

AN ANATOMICAL ATLAS, 

ILLUSTRATIVE OF THE STRUCTURE OF THE HUMAN BODY. 
BY HENRY II. SMITH, M.D. ; &c. 

UNDER THfi SUPERVISION OF 

WILLIAM E. HORNER, M.D., 

Professor of Anatomy in the University of Pennsylvania. 
In one volume, large imperial octavo, with about six hundred and fifty beautiful figures. 

With the view of extending the sale of this beautifully executed and complete "Anatomical At!. - 
publishers have prepared a new edition, printed on both sides of the page, thus materially reducing its cost, 
and enabling them to present it at a price about forty per cent, lower than former editions, while, at the same 
time, the execution of each plate is in no respect deteriorated, and not a single figure is omitted. 

These figures are well selected, and present a complete and accurate representation of that wonderful 
fabric, the human body. The plan of this Atlas .which renders it so peculiarly convenient for the student, and 
its superb artistical execution, have been already pointed out. We musl congratulate the student upon the 
completion of this Atlas, as it is the most convenient work of the kind that has yet appeared : and we must 
add, the very beautiful manner in which it is u got up" is so creditable to the country as to be flattering 
to our national pride. — American Medical Journal. 



HORNER'S DISSECTOR. 

THE UNITED STATES DISSECTOR; 

Being a new edition, with extensive modifications, and almost re-written, of 

"HORNER'S PRACTICAL ANATOMY." 

In one very neat volume, royal 1.2mo., of 440 pages, with many illustrations on wood. 



WILSON'S DISSECTOR, New Edition— (Just Issued.) 

THE DISSEOTOH; 

OR, PRACTICAL AMD SURGICAL, AN ATOIHY. 

BY ERASMUS WILSON. 

MODIFIED AND RE-ARRANGED BY 
PAUL BECK GODDARD, II. D. 

A NEW EDITION, WITH REVISIONS AND ADDITIONS. 

In one large and handsome volume, royal 12mo., with one hundred and fifteen illustrations. 

In passing this work again through the press, the editor has made such additions and improve- 
ments as the advance of anatomical knowledge has rendered necessary to maintain the work in the 
high reputation which it has acquired in the schools of the United States as a complete and faithful 
guide to the student of practical anatomy. A number of new illustrations have been added, espe- 
cially in the portion relating to the complicated anatomy of Hernia. In mechanical execution the 
work will be found superior to former editions. 



14 BLANC HARD & LEA'S PUBLICATIONS.— (P/iysioZo^y.) 

WORKS BY W. B. CARPEIHTER, M, D. 

NEW AND IMPROVED EDITION— (Just Ready.) 

PRINCIPLES OF HUMAN PHYSIOLOGY, 

WITH THEIR CHIEF APPLICATIONS TO 

PATHOLOGTj HTtf&lEKlE, AWI> FOUEMSIC MEHICIUfE. 

Fifth American from a New and Revised London Edition. 
Revised, with Notes, by F. a. SMITH, M. L\, 

Professor of Institutes of Medicine in the Pennsylvania Medical College. 

With over Three Hundred Illustrations. 

In one very large and handsome octavo volume. 

This edition of Dr. Carpenter's very popular work will be issued simultaneously with the new Lon- 
don edition, and therefore may be regarded as fully up to the most recent state of the subject. It will 
thus be found materially altered and improved, the author having used every exertion to incorpo- 
rate in it all the changes which the very numerous and important observations of the last few years 
have caused in this rapidly advancing science. To accomplish this, he has been compelled to 
re-write many portions, and to re-cast others, so that the present edition may be looked upon as • 
almost a new book. The passage of the work through the press has been carefully superintended 
by Prof. Smith, who has made such additions as were required to adapt it more particularly to the 
wants of the American student; and, with a greatly improved series of illustrations, and very 
superior style of mechanical execution, the publishers confidently present this edition as worthy 
a continuance of the universal favor with which this work has been received as a standard text- 
book for the student and practitioner. 

As a text-book it has been received into all our Colleges, and from a careful perusal we can recommend it 
to the student and to the profession at large, as the best exposition of the present condition of Physiology 
within their reach.— N. Y. Journal of Medicine. 

C®J?IF , .%M&TIirE I*MJ*$IOJLOGW—(JYow Meady.) 

PHIHOIPLES OP PHYSIOLOGY", 

GENERAL AND COMPARATIVE. 

THIRD edition, greatly enlarged. 

In one very handsome octavo volume, of over 1100 pages, with 321 beautiful wood-cuts. 
A truly magnificent work. In itself a perfect physiological study.— Ranking>s Abstract. 



CARPENTER'S MANUAL OF PHYSIOLOGY. 

NEW AND IMPROVED EDITION— (Just Issued.) 

ELEMENTS OP~PHYSIOLOGY, 

INCLUDING PHYSIOLOGICAL ANATOMY. 

SECOND AMERICAN, FROM A NEW AND REVISED LONDON EDITION. 

With One Hundred and Ninety Illustrations. In one very handsome octavo volume. 

In publishing the first edition of this work, its title was altered from that of the London volume, 
by the substitution of the word " Elements" for that of "Manual," and with the author's sanction, 
the title of " Elements" is still retained as being more expressive of the scope of the treatise. A 
comparison of the present edition with the former one will show a material improvement, the au- 
thor having revised it thoroughly, with the view of rendering it completely on a level with the 
most advanced state of the science. By condensing the less important portions, these numerous 
additions have been introduced without materially increasing the bulk of the volume, and while 
numerous illustrations have been added, and the general execution of the work improved, it has 
been kept at its former very moderate price. 

To pay that it is the best manual of Physiology now before the public, would not do sufficient justice to the 
auihor — Buffalo Med. Journal. 

In his former works it would seem that he had exhausted the subject of Physiology. In the present, he 
gives the essence, as it were, of the whole.— N. Y. Journal of Medicine. 

The be*t and mo?t complete expose" of modern physiology, in one volume, extant in the English language. 
— -St. Louis Med. Journal. 

Those who have occasion for an elementary treatise on physiology, cannot do better than to possess them- 
selves of the manual of Dr. Carpenter.— Medical Examiner. 



A New "Work by Dr. Carpenter— (Preparing.) 

THE VARIETIES OP MANKIND; 

Or, an Account of the Distinctive Characters of the Various Races of Men. 

WITH NUMEROUS ILLUSTRATIONS ON WOOD. 
In one handsome royal 12mo. volume. 



BLANCHARD & LEA'S PUBLICATIONS.— {Physiology.) 15 



DUNGLISON'S PHYSIOLOGY. 
New and much Improved Edition.— (Just Issued.) 

HUMAN PHYSIOLOGY. 

BY ROBLEY DUNGLISON, M. D., 

Professor of the Institutes of Medicine in the Jefferson Medical College, Philadelphia, etc. etc. 

SEVENTH EDITION. 

Thoroughly revised and extensively modified and enlarged, 
With nearly Five Hundred Illustrations. 

In two large and handsomely printed octavo volumes, containing nearly 1450 p 

On no previous revision of this work has the author bestowed more care than on the present, i l 
having been subjected to an entire scrutiny, not only as regards the important matters of which it 
treats, but also the language in which they are conveyed ; and on no former occasion has he fel. 
as satisfied with his endeavors to have the work on a level with the existing state of the science 
Perhaps at no time in the history of physiology have observers been more numerous, energetic, 
and discriminating than within the last few years. Many modifications of fact and inference have 
consequently taken place, which it has been necessary for the author to record, and to express his 
views in relation thereto. On the whole subject of physiology proper, as it applies to the functions 
executed by the different organs, the present edition, the author flatters himself, will therefore be 
found to contain the views of the most distinguished physiologists of all periods. 

The amount of additional matter contained in this edition may be estimated from the fact that 
the mere list of authors referred to in its preparation alone extends over nine large and closely printed 
pages. The number of illustrations has been largely increased, the present edition containing four 
hundred and seventy-four, while the last had but three hundred and sixty-eight; while, in addition 
to this, many new and superior wood-cuts have been substituted for those which were not deemed 
sufficiently accurate or satisfactory. The mechanical execution of the work has also been im- 
proved in every respect, and the whole is confidently presented as worthy the great and continued 
favor which it has so long received from the profession. 

It has long since taken rank as one of the medical classics of our language. To say that it is by far the best 
text-book of physiology ever published in this country, is bulechoing the general testimony of the profession. 
— A T . Y. Journal of Medicine. 

The most full and complete system of Physiology in our language.— Western Lancet 

The most complete and satisfactory system of Physiology in the English language — Amer. Med Journal 

The best work of the kind in the English language.— Stwiman's Jou 

We have, on two former occasions, brought tins excellent work under the notice of our readers, and we 
have now only to say that, instead of failing behind in the rapid march of physiological science, each edition 
bri'igs it nearer 10 the van. — British and Foreign Medical Review. 

A review of such a well-known work would be out of place at the present time. We have looked over it. 
and find, what we knew would he the case, that Dr. Dunglison has kept pace with the science to which he 
has devoted so much study, and of which he is one of the living ornaments. We recommend the work to the 
medical student as a valuable text-hook, and 10 all inquirers into Natural Science, as one winch w 
and delightfully repay perusal. — The New Orleans Medical and Surgical Journal. 

KIRKES AND PAGET'S PHYSIOLOGY. -(Lately Issued.) 

A MANUAL OF PHYSIOLOGY, 

FOR THE USE OF STUDENTS. 
BY WILLIAM SENHOUSE KIRKES, M. D., 

Assisted by JAMES FAGET, 

Lecturer on General Anatomy and Physiology in St. Bartholomew's Hospital. 

In one handsome volume, royal 12mo., of 550 pages, with US wood-cuts. 

An excellent work, and for students one of the best within reach —Boston Medical and Surgical Journal. 
One of the best little books on Physiology which we possess.— BraithwaiWs Retrospect. 
Particularly adapted to those who desire to possess a concise digest of the facts of Human Physiology. — 
British and Foreign Med.-Chirurg. Review. 

One of the best treatises which can be put into the hands of the student.— London Medical Gazette, 

We conscientiously recommend it as an admirable " Handbook of Physiology." — Loudon Jour, of Medicine 



SOLLY ON THE BRAIN. 

THE HUMAN BRAIN; ITS STRUCTURE, PHYSIOLOGY, AND DISEASES, 

WITH A DESCRIPTION OF THE TYPICAL FORM OF THE BRAIN ttX THE AXIMAL KINGDOM. 

BY SAMUEL SOLLY, F. R. S.. &c, 

Senior Assistant Surgeon to the St. Thomas' Hospital. cvc. 
From the Second and much Enlarged London Edition. In one octavo volume, with 120 Wood-cuts. 



HARRISON ON THE NERVES.— An Essay towards a correct theory of the Nervous System. In one 

octavo volume. 292 pages. 
MATTEUCCI ON LIVING BEINGS.- Lectures on the Physical Phenomena of Living Beings. Edited 

by Pereira. In one neat royal 12mo. volume, extra cloth, with cuts — 38S pages. 
ROt JET'S PHYSIOLOGY.— A Treatise on Animal and Vegetable Physiology", with over 400 illustrations on 

wood. In two octavo volumes, cloth 
ROGET'S OUTLINES —Outlines of Physiology aTid Phrenolosrv. In one octavo volume, cloth— 516 pages. 
ON THE CONNECTION BETWEEN PHYSIOLOGY AND INTELLECTUAL SCIENCE, la one 

12mo. volume, paper, price 25 cents. 
TODD & BOWMAN'S PHYSIOLOGY— Physiological Anatomy and Physiology of Maa. With numerous 

handsome wood-cuts. Parts I, II, and III, in one Svo. volume. 552 pp. Part IV will complete the work. 



16 BLANCHARD & LEA'S PUBLICATIONS— {Pathology.) 

NEARLY READY. 

AN ATLAS OF PATHOLOGICAL HISTOLOGY. 

BY GOTTLIEB GLUGE, M. D., 

Professor of Physiology and Pathological Anatomy in the University of Brussels. 

Translated, with Notes, by JOSEPH LEIDY, M. D. 
In one volume, very large imperial quarto, 

WITH THREE HUNDRED AND TWENTY FIGURES, PLAIN AND COLORED, ON TWELVE PLATES. 

The great and increasing interest with which this important subject is now regarded by the profession, 
and the rapid advances which it is making by the aid of" the microscope, have induced the publishers to pre- 
sent this volume, which contains all the most recent observations and results of European investigations. 
The text contains a complete exposition of the present state of microscopical pathology, while the plates are 
considered as among the most truthful and accurate representations which have been made of the pathologi- 
cal conditions of the tissues, and the volume as a whole may be regarded as a beautiful specimen of mechan- 
ical execution, presented at a very reasonable price. 

WILLIAMS* JPRUYCUPLES—JYew and Enlarged Edition, 

PRINCIPLES OF MEDICINE; 

Comprising General Pathology and Therapeutics, 

AND A BRIEF GENERAL VIEW OF 

ETIOLOGY, NOSOLOGY, SEMEIOLOGY, DIAGNOSIS, PROGNOSIS, AND HYGIENICS, 
BY CHARLES J. B. WILLIAMS, M. D., F. R. S., 

Fellow of the Royal College of Physicians, &c. 

Edited, with Additions, BY MEREDITH CLYMEB, M. D., 

Consulting Physician to the Philadelphia Hospital, &c. &c. 
THIRD AMERICAN, FROM THE SECOND AND ENLARGED LONDON EDITION. 

In one octavo volume, of 440 pages. 
BILLING'S PRINCIPLES, NEW EDITION— (Just Issued.) 

THE PRBNGSPLES OF HEilOSHE, 

BY ARCHIBALD BILLING, M. D., &c. 
Second American from the Fifth and Improved London Edition. 

In one handsome octavo volume, extra cloth, 250 pages. 
We can strongly recommend Dr. Billing's "Principles" as a code of instruction which should be con- 
stantly present to the mind of every well-informed and philosophical practitioner of medicine.— Lancet. 

MANUALS ON THE BLOOD AND URINE, 

In one handsome volume royal 12mo., extra cloth, of 460 large pages, with numerous illustratiQflfl. 

CONTAINING 

I. A Practical Manual on the Blood and Secretions of the Human Body. BY JOHN WILLIAM 
GRIFFITH, M. D., &c. 

II. On the Analysis of the Blood and Urine in health and disease, and on the treatment of Urinary 
diseases. BY G. OWEN REESE, M. D., F. R. S., &c. &c. 

III. A Guide to the Examination of the Urine in health and disease. BY ALFRED MARKWICK, 



NEW EDITION— (Just Issued.) 

URINARY "DEPOSITS; 

THEIR DIAGNOSIS, PATHOIOSY, AND THERAPEUTICAL INDICATIONS. 

BY GOLDINGr BIRD, A. M., M. D., &c. 

A NEW AMERICAN, FROM THE THIRD AND IMPROVED LONDON EDITION. 

In one very neat volume, royal 12mo., with over sixty illustrations. 
Though the present edition of this well-known work is but little increased in size, it will be found essen- 
tially modified throughout, and fully up to the present state of knowledge on its subject. The unanimous tes- 
timony of the medical press warrants the publishers in presenting it as a complete and reliable manual for 
the student of this interesting and important branch of medical science. 

ABERCROMBIE ON THE BRAIN.— Pathological and Practical Researches on Diseases of the Brain and 

Spinal Cord. A new edition, in one small 8vo. volume, pp. 324. 
BURROWS ON CEREBRAL CIRCULATION.— On Disorders of the Cerebral Circulation, and on the 

Connection between Affections of the Brain and Diseases of the Heart. In 1 Svo. vol., with co I'd pi's, pp. 216. 
BLAKISTON ON THE CHEST.— Practical Observations on certain Diseases of the Chest, and on the 

Principles of Auscultation. In one volume, 8vo., pp. 384. 
HASSE'S PATHOLOGICAL ANATOMY.— An Anatomical Description of the Diseasesof Respiration and 

Circulation. Translated and Edited by Swaine. In one volume, 8vo., pp. 379. 
FRICK ON THE URINE.— Renal Aflections, their Diagnosis and Pathology. In one handsome volume, 

royal 12mo., with illustrations. 
COPLAND ON PALSY.— Of the Causes, Nature, and Treatment of Palsy and Apoplexy. In one volume, 

rovat 12mo. (Just Issued.) 
VOGELS PATHOLOGICAL ANATOMY.— Pathological Anatomy of the Human body. Translated by 

Day. In one octavo volume, with plates, plain and colored. 
SIMON ; S PATHOLOGY.— Lectures on General Pathology. Publishing in the "Medical News and Li- 

Wrary," for 1852. 



BLANCHARD & LEA'S PUBLICATIONS— (Practice of Medicine.) 17 



THE PRACTICE OF MEDICINE. 

A TREATISE ON 

SPECIAL PATHOLOGY AND THERAPEUTICS. 

THIRD EDITION. 

BY KOBLEY DUNGLISON, M. D., 

Professor of the Institutes of Medicine in the Jefferson Medical College ; Lecturer on Clinical Medicine, <fec. 
In two large octavo volumes, of fifteen hundred pages. 

The student of medicine will find, in these two elegant volumes, a mine of facts, a gathering 
of precepts and advice from the world of experience, that will nerve him with courage, and faith- 
fully direct him in his efforts to relieve the physical sufferings of the race. — Boston Medical and 
Surgical Journal. 

Upon every topic embraced in the work the latest information will be found carefully posted up. 
Medical Examiner. 

It is certainly the most complete treatise of which we have any knowledge. There is scarcely a 
disease which the student will not find noticed. — Western Journal of Medicine and Surgery. 

One of the most elaborate treatises of the kind we have. — Southern Medical and Surg. Journal. 



NEW AND IMPROVED EDITIOX-(Now Ready.) 

THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE 

FEVERS OF THE UNITED STATES, 

BY ELISHA BARTLETT, M.D., 

Professor of Materia Medica and Medical Jurisprudence in the College of Physicians and Surgeons, N. Y. 

Third Edition, Revised and Improved, 

In one very neat octavo volume, of six hundred pages. 

In preparing a new edition of this standard work, the author has availed himself of such observ- 
ations and investigations as have appeared since the publication of his last revision, and he has 
endeavored in every way to render it worthy of a continuance of the very marked favor with which 
it has been hitherto received. 

The masterly and elegant treatise by Dr. Bartlett is invaluable to the American student and practitioner. 
— Dr. Holmes's Report to the Nat. Med. Association. 

We regard it, from the examination we have made of it, the best work on fever extant, in our language, 
and as such cordially recommend it to the medical public— St. Louis Med. and Surg. Journal. 



DISEASES OF THE HEART, LUNGS, AND APPENDAGES ; 

THEIR SYMPTOMS AND TREATMENT. 
BY W. H. WALSHE, M.D., 

Professor of the Principles and Practice of Medicine in University College, London, 8cc. 
In one handsome volume, large royal 12mo. 

THE CYCLOPEDIAOF PRACTICAL MEDICINE; 

COMPRISING 

Treatises on the Nature and Treatment of Diseases, Materia Medica, and Thera- 
peutics, Diseases of "Women and Children, Medical Jurisprudence, &.c. &c. 

EDITED BY 

JOHN FORBES, M. D., F. R. S., ALEXANDER TWEEDIE, M.D., F.R. S., 
AND JOHN CONOLLY, M. D.| 

Revised, with Additions, 

BY ROBLEY DUNGrLISON, M. D. 

THIS WORK IS NOW COMPLETE, AND FORMS FOUR LARGE SUPER- ROYAL OCTAVO VOLUMES, 

Containing Thirty-two Hundred and Fifty-four unusually large Pages in Double Columns, Printed 
on Good Paper, with a new and clear type. 

THE WHOLE WELL AND STRONGLY BOUND. WITH RAISED BANDS AND DOUBLE TITLES. 

This work contains no less than FOUR HUNDRED AXD EIGHTEEN DISTINCT TREATISES, 

By Sixty-eight distinguished Physicians. 

The most complete work on Practical Medicine extant; or, at least, in our language.— B uffalo Medical 
and Surgical Journal. 

For reference, it is above all price to every practitioner. — Western Lancet. 

One of the most valuable medical publications of the day — as a work of reference it is invaluable. — 
Western Journal of Medicine and Surgery. 

It has been 10 us. both as learner and teacher, a work for ready and frequent reference, one in which 
modern English medicine is exhibited in the most advantageous light. — Medical Examiner. 

We rejoice that mis work is to be placed within the reach 0fthepr0fessi0ninthisc0untr3~.it being unques- 
tionably one of very great value to the practitioner. This estimate of it has not been formed from a "hasty ex- 
aminauon, but after an intimate acquaintance derived from frequent consultation of it during the past nine or 
ten years. The editors are practitioners of established reputation, and the list of contributors embraces many 
of the most eminent professors and teachers of London, Edinburgh. Dublin, and Glasgow. Ii is. indeed, the 
great merit of this work that the principal articles have been furnished by practitioners who have not only 
devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities 
for an extensive practical acquaintance with them.— and' whose reputation carries the assurance of their 
competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just 
authority.— American Medical Journal. 



18 BLANCHARD & LEA'S PUBLICATIONS.— (Practice of Medicine.) 

WATSON'S PRACTICE OF MEDICINE-New Edition. 

LECTURES ON THE 

PRINCIPLES AND PRACTICE OF PHYSIC. 

BY THOMAS WATSON, M. D., &o. &c. 
Third American, from the last London Edition. 

REVISED, WITH ADDITIONS, BY D. FRANCIS CONDIE, M. D., 

Author of " A Treatise on the Diseases of Children," &c. 

IN ONE OCTAVO VOLUME, 

Of nearly ELEVEN HUNDRED LARGE PAGES, strongly bound with raised bands. 

To say that it is the very best work on the subject now extant, is but to echo the sentiment of the medical 
press throughout the country. — N. O. Medical Journal. 

Regarded on all hands as one of the very best, if not the very best, systematic treatise on practical medi- 
cine extant. — St. Louis Med. Journal. 

As a text-book it has no equal; as a compendium of pathology and practice no superior. — N. Y. Annalist. 

We know of no work better calculated for being placed in the hands of the student, and for a text-book; 
on every important potnt the author seems to haveposted up his knowledge to the day.— Amer. Med. Journal. 

One of the most practically useful books that ever was presented to the student. — N. Y. Med. Journal. 



NEW AND IMPROVED EDITION- (Now Ready.) 

ON DISEASES - OF THE SKIN. 

BY ERASMUS WILSON, F. R. S'., 

Author of' - Human Anatomy," &c. 

THIRD AMERICAN FROM THE THIRD LONDON EDITION. 

In one neat octavo volume, extra cloth, 4S0 pages. 

Also, to be had with fifteen beautiful steel plates, embracing 165 figures, plain 

and colored, representing the Normal Anatomy and Pathology of the Shin. 

ALSO, THE PLATES SOLD SEPARATE, IN BOARDS. 

This edition will be found in every respect much improved over the last. Considerable addi- 
tions have been made, the arrangement altered, and the whole revised so as to make it fully on a 
level with the existing state of knowledge on the subjects treated. 

As a practical guide to the classification, diagnosis, and treatment of the diseases of the skin, the book is 
complete. We know nothing, considered in ihis aspect, better in our language ; it is a safe authority on all 
the ordinary matters which, in this range of diseases, engage the practitioner's attention, and possesses the 
high quality— unknown, we believe, to every older manual — of being on a level with science's high-water 
mark — a sound book of practice. — London Medical Times. 



WILSON ON SYPHILIS- (Now Ready.) 

ON CONSTITUTIONAL ml HEREDITARY SYPHILIS ; 

AND ON SYPHILITIC ERUPTIONS. 
BY ERASMUS WILSON, F. R. S., 

Author of" Human Anatomy," " Diseases of the Skiu, : ' &c. 
In one very handsome volume, small 8vo., with four beautiful colored plates, 
Presenting accurate representations of more than thirty varieties of Syphilitic Diseases of the Skin. 
This work is the result of extensive practical experience in the treatment of this disease, and 
presents some new views on this difficult and important subject, illustrated by numerous cases. 



BENEDICT'S CHAPMAN.— Compendium of Chapman's Lectures on the Practice of Medicine. One neat 
volume, 8vo., pp. 258. 

BUDD ON THE LIVER.— On Diseases of the Liver. In one very neat Svo. vol., with colored plates and 
wood-cuts, pp. 392. 

CHAPMAN'S LECTURES.— Lectures on Fevers, Dropsy, Gout, Rheumatism, &c. &c. In one neat Svo. 
volume, pp. 450. 

THOMSON ON THE SICK ROOM.— Domestic management of the sick Room, necessary in aid of Medical 
Treatment for the cure of Diseases. Edited by R. E. Griffith, M. D. In one large royal 12mo. volume, with 
wood-cuts, pp. 360. 

HOPE ON THE HEART.— A Treatise on the Diseases of the Heart and Great Vessels. Edited by Pen- 
nock. In one volume. 8vo , with plates, pp. 572. 

LALLEMAND ON SPERMATORRHOEA.— The Causes, Symptoms, and Treatment of Spermatorrhoea. 
Trarslated and Edited by Henry J. McDougal. In one volume, Svo., pp. 320. 

PHILIPS ON SCROFULA.— Scrofula: its Nature, its Prevalence, its Causes, and the Principles of its 
Treatment. In one volume, 8vo., with a plate, pp. 350. 

WHITEHEAD ON ABORTION, &c— The Causes and Treatment of Abortion and Steriliiy; being the 
Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions of the Uterus. In 
one volume, 8vo., pp. 368. 

WILLIAMS ON RESPIRATORY ORGANS.— A Practical Treatise on Diseases of the Respiratory Or- 
gans; including Diseases of the Larynx, Trachea, Lungs, and Pleurae. With numerous Addiiions and 
Notes by M. Clymer, M. D. With wood-cuts. In one octavo volume, pp. 508. 

DAY ON OLD AGE.— A Practical Treatise on the Domestic Management and more important Diseases of 
Advanced Life. With an Appendix on a new and successful mode of treating Lumbago and other forms 
of Chronic Rheumatism. 1 vol. 8vo., pp. 226. 

CLYMER ON FEVERS.— Fevers, their Diagnosis, Pathology, and Trealment. Prepared, with large Ad- 
ditions, from " Tweedie's Library of Practical Medicine." In one vol 8vo., pp. 604. . 



BLANCHARD & LEA'S PUBLICATIONS.— (Diseases of Females.) 19 



MEIGS ON FEMALES, New and Improved Edition— (Lately Issued.) 

WOMAN; HER DISEASES" AND THEIR REMEDIES; 

A SERIES OF LETTERS TO HIS CLASS. 

BY C. D. MEIGS, M. J)., 

Professor of Midwifery and Diseases of Women and Children in the Jefferson Medical College of 

Philadelphia, &c. &e. 

In one large and beautifully printed octavo volume, of nearly seven hundred large pages. 

' I am happy to offer to my Class an enlarged and amended edition of my Letters on the Pis- 
eases of Women; and I avail myself of this occasion to return my heartfelt thankb to them, and 
to our brethren generally, for the flattering manner in which they have accepted this fruit of my 
labor." — Preface. 

The value attached to this work by the profession is sufficiently proved by the rapid ex- 
haustion of the first edition, and consequent demand for a second. In preparing this the 
author has availed himself of the opportunity thoroughly to revise and greatly to improve 
it. The work will therefore be found completely brought up to the day, and in every way 
worthy of the reputation which it has so immediately obtained. 

Professor Meigs has enlarged and amended this crreat work, for such it unquestionably is, having passed 
the ordeal of criticism at home and abroad, hut been improved ihereby : for in this new edition the author 
has introduced real improvements, and increased the value and utility of the hook immeasurably. It presents 
BO many novel, bright and sparkling thoughts; ^uch an exuberance of new ideas on almost every page. 
that we confess ourselves to have become enamored with the book and its author; and cannot withhold 
our congratulations from our Philadelphia confreres, that such a teacher is in their service. We regret *.hat 
our limits will not allow of a more extended notice of this work, but must content ourselves wiili thus com- 
mending it as worthy of diligent perusal by physicians as well as students, who are seekingto be thoroughly 
instructed in the important practical subjects of which it treat*— N. Y. died. Gazette. 

It contains a vast amount of practical knowledge, by one who has accurately observed and retained the 
experience of many years, and who tells the result in a free, familiar, and pleasant manner.— Dublin Quar- 
terly Journal. 

There i* an off-hand fervor, a glow and a warm-heartedness infecting the effort of Dr. Meiijs. which is en- 
tirely captivating, and which absolutely hurries the reader through from beginning to end. Besides, the 
book teems with solid instruction, and it shows the very highest evidence of ability, viz.. the clearness v.-.'.h 
which the information is presented. We know of no better test of one's understanding a subject than the 
evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, un- 
der the pencil of Prof. Meigs, are isolated and made to stand out in such bold relief, as to produce distinct 
impressions upon the mind and memory of the reader. — The Charleston Medical Journal. 

The merits of the first edition of this work were so generally appreciated, and with such a high degree of 
favor by the medical profession throughout the Union, that we are not surprised in seeing a second edition 
of it. It is a standard work on the diseases of females, and in many respects is one of it of its 

kind in the English language. Upon the appearance of the first edition, we gave the work a cordial recep- 
tion, and spoke of it in the warmest terms of commendation. Time has not changed the favorable estimate 
we placed upon it, but has rather increased our convictions of its superlative merits. But we do not now 
deem it necessary to say more than to commend this work, on the diseases of women, and the remedies 
for them, to the attention of those practitioners who have not supplied themselves with it. The most select 
library would be imperfect without it. — The Western Journal of Medicine and Su> _ 

He is a bold thinker, and possesses more originality of thought at d style than almost any American writer 
on medical subjects. If he is not an elegant writer, there is at least a freshness— a raciness in his mode of 
expressing himself— that cannot fail to draw the reader after him. even to the close of his work : you cannot 
nod over his pages; he stimulates rather than narcotises your senses, and the reader cannot lay aside these 
letters when once he enters into their merits. This, the second edition, is much amended and enlarged, and 
affords abundant evidence of the authors talents and industry. — N. O. Medical and Surgical Journal. 

The practical writings of Dr. Meigs are second to none.— The N. Y. Journal of Medicine. 

The excellent practical directions contained in this volume give it great utility, which we trust will not be 
lost upon our older colleagues ; with some condensation, indeed, we should think it well adapted for trans- 
lation into German. — Zeitschri/tfur die Gesammte Medecin. 



NEW AND IMPROVED EDITION-(Lately Issued.) 

A TREATISE ON THE DISEASES OF FEMALES, 

AND ON THE SPECIAL HYGIENE OF THEIR SEX, 
BY COLOMBAT DE L'ISERE, M. D. 

TRANSLATED, WITH MANY NOTES AND ADDITIONS, BY C. D. MEIGS, M. D. 

SECOND EDITION, REVISED AND IMPROVED. 

In one large volume, octavo, of seven hundred and twenty pages, with numerous wood-cuts. 
We are satisfied it is destined to take the front rank in this department of medical science. It is in fact a 
complete exposition of the opinions and practical methods of all the celebrated practitioners of ancient and 
modern times. — New York Jour n. of Medicine. 



ASHWSLL ON THE DISEASES OF FEHALES. 

A PRACTICAL TREATISE GW THE DISEASES PECULIAR TO WOMEN. 

ILLUSTRATED BY CASES DERIVED FROM HOSPITAL AND PRIVATE PRACTICE. 

BY SAMUEL ASH WELL. M. D. With Additions by PAUL BECK GODDARD, M. D. 
Second American edition. In one octavo volume, of 520 pages. 
One of the very best works ever issued from the press on the Diseases of Females. — Western Lancet. 



ON THE CAUSES AND TREATMENT OF ABORHON AND STERILITY. By James Whitehead, 
M. D., &c. In one volume octavo, of about tnree hundred and seventy- five pages. 



BLANCHARD & LEA'S PUBLICATIONS.— (Pw«we* of Females.) 
NEW AND IMPROVED EDITION. 

THE DISEASES~OF FEMALES. 
INCLUDING THOSE OF PREGNANCY AND CHILDDED. 

BY FLEETWOOD CHURCHILL, M. D., M. R. I. A., 

Author of "Theory and Practice of Midwifery," "Diseases of Females," &c. 

A New American Edition, Revised by the Author. 

In one large and handsome octavo volume of 632 pages, with wood-cuts. 

To indulge in panegyric, when announcing the fifth edition of any acknowledged medical'authority, were 
to attempt to " gild refined gold." The work announced above, has too long been honored with the term 
" classical" to leave any doubt as to its true worth, and we content ourselves with remarking, that the author 
has carefully retained the notes of Dr. Huston, who edited the former American edition, thus really enhanc- 
ing the value of the work, and paying a well-merited compliment. All who wish to be "posted up" on all 
that relates to the diseases peculiar to the wife, the mother, or the maid, will hasten to secure a copy of this 
most admirable treatise. — The Ohio Medical and Surgical Journal. 

We know of no author who deserves that approbation, on " the diseases of females," to the same extent 
that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject, and it may be 
commended to practitioners and students as a masterpiece in its particular department. The former editions 
of this work have been commended strongly in this journal, and they have won their way to an extended, 
and a well deserved popularity. This fifth edition, before lis, is well calculated to maintain Dr. Churchill's 
high reputation. It was revised and enlarged by the author, for his American publishers, and it seems to us, 
that there is scarcely any species of desirable information on its subjects, that may not be found in this work. 
— The Western Journal of Medicine and Surgery. 

We are gratified to announce a new and revised edition of Dr. Churchill's valuable work on the diseases 
of females. We have ever regarded it as one of the very best works on the subjects embraced within its 
scope, in the English language ; and the present edition, enlarged and revised by the author, renders it still 
more entitled to the confidence of the profession. The valuable notes of Prof. Huston have been retained, 
and contribute, in no small degree, to enhance the value of the work. It is a source of congratulation that 
the publishers have permitted the author to be, in this instance, his own editor, thus securing all the revision 
which an author alone is capable of making. — The Western Lancet. 

As a comprehensive manual for students, or a work of reference for practitioners, we only speak with 
common justice when we say that it surpasses any other that has ever issued on the same subject from the 
British press.— The Dublin Quarterly Journal. 



Churchill's Monographs on Females. — (Lately Issued.) 

ESSAYS ON THE PUERPERAL~FEVER, AND OTHER DISEASES 

PECULIAR TO WOMEN. 

SELECTED FROM THE WRITINGS OF BRITISH AUTHORS PREVIOUS TO THE CLOSE OF 
THE EIGHTEENTH CENTURY. 

Edited by FLEETWOOD CHURCHILL, M. D., M. R. I. A., 
Author of "Treatise on the Diseases of Females," &c. 

In one neat octavo volume, of about four hundred and fifty pages. 

To these papers Dr. Churchill has appended notes, embodying whatever information has been laid before 
the profession since their authors' time. He has also prefixed to the essays on puerperal fever, which occu- 
py the larger portion of the volume, an interesting historical sketch of the principal epidemics of that disease. 
The whole forms a very valuable collection of papers by professional writers of eminence, on some of the 
most important accidents to which the puerperal female is liable. — American Journal of Medical Sciences. 



JBEJYJYETT OJY THE UTERUS— {JYetv Edition, JS*ow Ready.) 
A PRACTICAL TREATISE ON 

INFLAMMATION OF THE UTERUS AND ITS APPENDAGES 

AND ON ULCERATION AND INDURATION OF THE NECK OF THE UTERUS. 
BY HENRY BENNETT, M. D., 

Obstetric Physician to the Western Dispensary. 

Third American Edition. 

In one neat octavo volume of 350 pages, with wood-cuts. 

Few works issue from the medical press which are at once original and sound in doctrine ; but such, we 
feel assured, is the admirable treatise now before us. The important practical precepts which the author 
inculcates are all rigidly deduced from facts. . . . Every page of the book is good, and eminently practical. 
So far as we know and believe, it is the best work on the subject on which it treats.— Monthly Journal of 
Medical Science. 



A TREATISE ON THE DISEASES OF FEMALES. 
BY W. P. DEWEES, M. D. 

NINTH EDITION. 
In one volume, octavo. 532 pages, with plates. 



BLANCHARD & LEA'S PUBLICATIONS —{Diseases of Children.) 21 



MEIGS ON CHILDREN— Just Issued. 
OBSERVATIONS ON 

CERTAIN OF THE DISEASES OF YOUNG CHILDREN, 

BY CHARLES D. MEIGS, M. V., 

Professor of Midwifery and of the Diseases of Women and Children in the Jefferson 
Medical College of Philadelphia, &c. &c. 

In one handsome octavo volume of 214 pages. 

While this work is not presented to the profession as a systematic and complete treatise on In- 
fantile disorders, the importance of the subjects treated of, and the interest attaching to the views 
and opinions of the distinguished author must command for it the attention of all who are called 
upon to treat this interesting class of diseases. 

It puts forth no claims as a systematic work, but contains an amount of valuable and useful matter, 
scarcely to he found in the same space in our home literature. It can not hut prove an acceptable offering 
to the profession at large. — N. Y. Journal of Medicine. 

The work before us is undoubtedly a valuable addition to the fund of information which hag already been 
treasured up on the subjects in question. It is practical, und therefore eminently adapted to the general 
practitioner. Dr. Meigs' works have the same fascination which belongs to himself.— Medical Examiner. 

This is a most excellent work on the obscure diseases of childhood, and will afford the praetilioner and 
student of medicine much aid in their diagnosis and ireaiment.— The Boston Medical and Surgical Journal. 

We take much pleasure in recommending this excellent little work to the attention of med cs.1 practition- 
ers. It deserves their attention, and after they commence it* perusal, they will not willingly abandon it. 
until they have mastered its contents. We read the work while suffering from a carbu 
naling pages often beguiled us into forgetfulness of agonizing pain. May it teach others to relieve the afflic- 
tions of the young. — The Western Journal of Medicine and Surgery. 

All of which topics are treated with Dr. Meigs' acknowledged ability and original diciion. The work i? 
neither a systematic nor a complete treatise upon the disease* of children, but a fragment winch may be con- 
sulted with much advantage.— Southern Medical and Surgical Journal. 



NEW WORK BY DR. CHURCHILL. 
ON THE 

DISEASES OF INFANTS AND CHILDREN. 

BY FLEETWOOD CHURCHILL, M. D., M. It. I. A., 

Author of "Theory and Practice of Midwifery," "Diseases of Females," tec. 
In one large and handsome octavo volume of over 600 pages. 

From Dr. Churchill's known ability and industry, we were led to form high expectations of this work : noi 
were we deceived. Its learned author seems to have set no bounds to his researches in collecting informa- 
tion which, with his usual systematic address, he has disposed of in the most clear and concse manner, so 
as to lay before the reader every opinion of importance bearing upon the subject under consideration. 

We regard this volume as possessing more claims to completeness than any other of the kind with which 
we are acquainted. Most cordially and earnestly, therefore, do we commend it to our professional brethren, 
and we feel assured that the stamp of their approbation will in due time be impressed upon it. 

After an attentive perusal of its contents, we hesitate not to say, that it is one of the most comprehensive 
ever written upon the diseases of children, and that, for copiousness of reference, extentof research, and per- 
spicuity of detail, it is scarcely to be equalled, and not to be excelled in any language.— Dublin Quarterly 
Journal. 

The present volume will sustain the reputation acquired by the author from his previous works. The 
reader will find in it full and judicious directions for the management of infants at birth, and a compendious, 
but clear, account of the diseases to which children are liable, and the most successful mode of treating them. 
We must not close this notice without calling attention to the author's style, which is perspicuous and 
polished to a degree, we regret to say, not generally characteristic of medical works. We recommend the 
work of Dr. Churchill most cordially, both to students and practitioners, as a valuable and reliable guide in 
the treatment of the diseases of children. — Am. Journ. of the Med. Sciences. 

After this meagre, and we know, very imperfect notice, of Dr. Churchill's work, we shall conclude by 
saying, that it is one that cannot fail from its copiousness, extensive research, and general accuracy, to exalt 
still higher the reputation of the author in this country. The American reader will be particularly pleased 
to find that Dr. Churchill has done full justice throughout his work, to the various American authors on this 
subject. The names of Dewees, Eberle, Condie, and Stewart, occur on nearly every page, and these authors 
are constantly referred to by the author in terms of the highest praise, and with the most liberal courtesy. — 
Tlie Medical Examiner. 

We know of no work on this department of Practical Medicine which presents so candid and unpreju- 
diced a statement or posting up of our actual knowledge as this.— N. Y. Journal of Medicine. 

Its claims to merit, both as a scientific and practical w r ork, are of the highest order. Whilst we would 
not elevate it above every other treatise on the same subject, we certainly believe that very few are equal 
to it, and none superior.— Sou: 'hem Med. and Surg. Journal. 



22 BLANCHARD & LEA'S PUBLICATIONS.— (Diseases of Children.) 

New and Improved Edition. 
A PRACTICAL TREATISE ON THE 

DISEASES OF CHILDREN. 

BY D. FRANCIS CONDIE, M. D. ; 

Fellow of the College of Physicians, &c. &c. 
Third edition, revised and augmented. In one large volume, 8vo., of over 700 pages. 

In the preparation of a third edition of the present treatise, every portion of it has been subjected 
to a careful revision. A new chapter has been added on Epidemic Meningitis, a disease which, 
although not confined to children, occurs far more frequently in them, than in adults. In the other 
chapters of the work, all the more important facts that have been developed since the appearance 
of the last edition, in reference to the nature, diagnosis, and treatment of the several diseases of 
which they treat, have been incorporated. The great object of the author has been to present, in 
each succeeding edition, as full and connected a view as possible of the actual state of the pa- 
thology and therapeutics of those affections which most usually occur between birth and puberty. 

To the present edition there is appended a list of the several works and essays quoted or referred 
to in the body of the work, or which have been consulted in its preparation or revision. 

Every important fact that has been verified or developed since the publication of the previous edition) 
either in relation to the nature, diagnosis, or treatment of the diseases of children, have been arranged and 
incorporated into the body of the work ; thus posting up to date, to use a counting-house phrase, all the 
valuable facts and useful information on the subject. To the American practitioner, Dr. Condie's remarks 
on the diseases of children will be invaluable, ana we accordingly advise those who have failed to read this 
work to procure a copy, and make themselves familiar with its sound principles. — The New Orleans Medical 
and Surgical Journal. 

We feel persuaded that the American Medical profession will soon regard it, not only as a very good, but 
as the very best " Practical Treatise on the Diseases of Children."— American Medical Journal. 

We pronounced the first edition to be the best work on the Diseases of Children in the English language, 
and, notwithstanding all that has been published, we still regard it in that light. — Medical Examiner. 
From Professor Wm. P. Johnston, Washington, D. C. 

I make use of it as a text-book, and place it invariably in the hands of my private pupils. 
From Professor D. Humphreys Storer, of Boston. 

I consider it to be the best work on the Diseases of Children we have access to, and as such recommend it 
to all who ever refer to the subject. 

From Professor M. M. P alien, of St. Louis. 

I consider it the best treatise on the Diseases of Children that we possess, and as such have been in the 
habit of recommending it to my classes. 

Dr. Condie's scholarship, acumen, industry, and practical sense are manifested in this, as in all his nu- 
merous contributions to science.— Dr. Holmes^s Report to the American Medical Association. 

Taken as a whole, in our judgment, Dr. Condie's Treatise is the one from the perusal of which the practi- 
tioner in this country will rise with the greatest satisfaction.— Western Journal of Medicine and Surgery. 

One of the best works upon the Diseases of Children in the English language.— Western Lancet. 

We feel assured from actual experience that no physician's library can be complete without a copy of this 
work. — N. Y. Journal of Medicine. 

Perhaps the most full and complete work now before the profession of the United States ; indeed, we may 
say in the English language. It is vastly superior to most of its predecessors.— Transylvania Med. Journal. 

A veritable pediatric encyclopaedia, and an honor to American medical literature.— Ohio Medical and Sur- 
gical Journal. 

WEST OJV DISEASES OE CHILnUEJV. 

LECTURES ON THE 

DISEASES OF INFANGY AND CHILDHOOD. 

BY CHARLES WEST, M. D., 

Senior Physician to the Royal Infirmary for Children, &c. &c. 
In one volume, octavo. 

Every portion of these lectures is marked by a general accuracy of description, and by the soundness of 
the views set forth in relation to the pathology and therapeutics of the several maladies treated of. The lec- 
tures on the diseases of the respiratory apparatus, about one-third of the whole number, are particularly 
excellent, forming one of the fullest and most able accounts of these affections, as they present themselves 
during infancy and childhood, in the English language. The history of the several forms of phthisis during 
these periods of existence, with their management, will be read by all with deep interest.— The American 
Journal of the Medical Sciences. 

The Lectures of Dr. West, originally published in the London Medical Gazette, form a most valuable 
addition to this branch of practical medicine. For many years physician to the Children's Infirmary, his 
opportunities for observing their diseases have been most extensive, no less than 14,000 children having been 
brought under his notice during the past nine years. These have evidently been studied with great care, 
and the result has been the production of the very best work in our language, so far as it goes, on the dis- 
eases of this class of our patients. The symptomatology and pathology of their diseases are especially 
exhibited most clearly; and we are convinced that no one can read with care these lectures without deriv- 
ing from them instruction of the most important kind. — Charleston Med. Journal. 



A TREATISE 

ON THE PHYSICAL AND MEDICAL TREATMENT OP CHILDREN. 

BY W. P. DEWEES, M. D. 

Ninth edition. In one volume, octavo, of 548 pages. 



BLANCIIARD & LEA'S PUBLICATIONS— (Obstetrics.) 23 



NEW AND IMPROVED EDITION— (Now Ready.) 

OBSTETRICS: 

THE SCIENCE AND THE ART. 

BY CHARLES D. MEIGS, M.D., 

Professor of Midwifery and the Diseases of Women and Children in the Jefferson Medical College, 

Philadelphia| &e. &c. 
Second Edition, Revised and Improved, with 131 Illustrations. 
In one beautifully printed octavo volume, of seven hundred and fifty-two large pages. 
The rapid demand for a second edition of this work is a sufficient evidence that it hns supplied 
a desideratum of the profession, notwithstanding the numerous treatises on the same subject which 
have appeared within the last few years. Adopting a system of his own, the author has combined 
the leading principles of his interesting and difficult subject, with a thorough exposition of its rules 
of practice, presenting the results of long and extensive experience and of familiar acquaintance 
with all the modern writers on this department of medicine. As an American treatise on Mid- 
wifery, which has at once assumed the position of a classic, it possesses peculiar claims to the at- 
tention and study of the practitioner and student, while the numerous alterations and revisions 
which it has undergone in the present edition are shown by the great enlargement of the work, 
which is not only increased as to the size of the page, but also in the number. Among other addi- 
tions may be mentioned ^^ .— ™~™ „ 

A NEW AND IMPORTANT CHAPTER ON "CHILD-BED FEVER." 

As an elementary treatise— concise, hut, withal, clear and comprehensive- we know of no one better 

adapted for the use of the student; while the young practitioner will find in it a body or sound I doctrine, 

and a series of excellent practical directions, adapted to all the conditions of the various forms of labor 

and their results, which he will be induced, we are persuaded, again and again to consult, and always with 

P 7t has seldom been our lot to peruse a work upon the subject, from which we have received greater satis- 
faction, and which we believe to be better calculated to communicate to the student correct and jietiime 
views upon the several topics embraced within the scope of its teachings.— American Journal of the Medical 

C \Veare acquainted with no work on midwifery of greater practical value.— Boston Medicaland Surgical 
Journal. „,.,,-. 

Worthy the reputation of its distinguished author.— Medical Examiner. 

We most sincerely recommend it. both to the student and practitioner, as a more complete and valuable 
work on the Science and Art of Midwifery, than any of the numerous reprints and American editions ot 
European works on the same subject.— N. Y. Annalist. . 

We have, therefore, great satisfaction in bringing under our reader's notice the matured views ot the 
highest American authority in the department to which he has devoted his hie and talents.— London Medical 

Aii author of established merit, a professor of Midwifery, and apractitionerofhigh reputation and immense 
experience-we may assuredly regard his work now before us as represent.ng the most advanced s ate of 
obstetric science in America up to the time at which he writes. We consider Dr. Meigs book as a valuable 
acquisition to obstetric literature, and one that will very much assist the practitioner under many circum- 
stances of doubt and perplexity.— The Dublin Quarterly Journal. . _^.„ 

These various heads are subdivided so well, so lucidly explained, that a good memory is all thatis neces- 
sary in order to put the reader in possession of a thorough knowledge of this important subject. Dr. Meigs 
has conferred a great benefit on the profession in publishing this excellent work.— St. Louis Medical and 
Surgical Journal. 

TYLER SMITH ON PARTURITION. 

ON PARTURITION, 

AND THE PRINCIPLES AND PRACTICE OP OBSTETRICS. 

BY W. TYLER SMITH, M. D., 

Lecturer on Obstetrics in the Hunterian School of Medicine, &c. &c. 
In one large duodecimo volume, of 400 pages. 

The work will recommend itself by its intrinsic merit to every member of the profession.- Lancet. 

We can imagine the pleasure with which William Hunter or Denman would have welcomed the present 
work: certain!* the most valuable contribution to obstetrics that has been made since their own day. 1-or 
ourselves, we consider its appearance as the dawn of a new era in this department of medicine. J\edo 
most cordially recommend the work as one absolutely necessary to be studied by every accoucheur. It will, 
we mav add. prove equally interesting and instructive to the student, the general practitioner, and pure ob- 
stetrician. It was a bold undertaking to reclaim parturition for Reflex Physiology, and it has been well per- 
formed. — London Journal of Medicine. 

LEE'S CLINICAL MIDWIFERY. 

CLINICAL MIDWIFERY, 

C0MP c^^ 

BY ROBERT LEE, M. D., F. R. S., &c. 

From the 2d London Edition. 
In one royal 12mo. volume, extra cloth, of 23S pages. 
More instructive to the juvenile practitioner than a score of systematic works.— Lancet. 
An invaluable record for the practitioner.— N. Y. Annalist. 
A storehouse of valuable facts and precedents.— American Journal of the Medical Sciences. 



24 BLANCHARD & LEA'S PUBLICATIONS.— (Obstetrics.) 

CHURCHILL'S MIDWIFERY, BY CONDIE, NEW AND IMPROVED EDITION-(Just Issued.) 

THEORY AND PRACTICE OF MIDWIFERY. 

BY FLEETWOOD CHURCHILL, M. D., &c. 

A NEW AMERICAN FROM THE LAST AND IMPROVED ENGLISH EDITION, 

EDITED, WITH NOTES AND ADDITIONS, 

BY D. FRANCIS CONDIE, M. D., 

Author of a " Practical Treatise on the Diseases of Children," &c. 
WITH ONE HUJVBRED JLJYD THIRT1T-JYIJVM ILIjUSTR&TIOJYS* 

In one very handsome octavo volume. 

In the preparation of the last English edition, from which this is printed, the author has spared 
no pains, with the desire of bringing it thoroughly up to the present state of obstetric science. 
The labors of the editor have thus been light, but he has endeavored to supply whatever he has 
thought necessary to the work, either as respects obstetrical practice in this country, or its 
progress in Europe since the appearance of Dr. Churchill's last edition. Most of the notes of the 
former editor, Dr. Huston, have been retained by him, where they have not been embodied by the 
author in his text. The present edition of this favorite text-book is therefore presented to the pro- 
fession in the full confidence of its meriting a continuance of the great reputation which it has 
acquired as a work equally well fitted for the student and practitioner. 

To beslow praise on a book that has received such marked approbation would be superfluous. We need 
only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical pub- 
lic, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the 
student, may all have recourse to its pages, and derive from their perusal much interest and instruction in 
everything relating to theoretical and practical midwifery.— Dublin Quarterly Journal of Medical Science. 

A work of very great merit, and such as we can confidently recommend to the study of every obstetric 
practitioner.— London Medical Gazette. 

This is certainly the most perfect system extant. It is the best adapted for the purposes of a text-book, and 
that which he whose necessities confine him to one book, should select in preference to all others.— Southern 
Medical and Surgical Journal. 

The most popular work on Midwifery ever issued from the American press. — Charleston Medical Journal. 

Certainly, in our opinion, the very best work on the subject which exists.— N. Y. Annalist. 

Were we reduced to the necessity of having but one work on Midwifery, and permitted to choose, we would 
unhesitatingly take Churchill.— Western Medical and Surgical Journal. 

It is impossible to conceive a more useful and elegant Manual than Dr. Churchill's Practice of Midwifery. 
—Provincial Medical Journal. 

No work holds a higher position, or is more deserving of being placed in thehandsofthe tyro, the advanced 
student, or the practitioner. — Medical Examiner. 



JYEW* JEMTIOJX* OF R&JflSBOTHJlJtl OJV JPJiRTURITTOJ\*-(JVow Ready, 1851.) 

THE PRINCIPLES AND PRACTICE OP 

OBSTETRIC MEDICINE AND SURGERY, 

In reference to the Process of Parturition. 

BY FRANCIS H. RAMSBOTHAM, M.D., 

Physician to the Royal Maternity Charity, &c. &c. 

SIXTH AMERICAN, FROM THE LAST LONDON EDITION. 

Illustrated with One Hundred and Forty-eight Figures on Fifty-five Lithographic Plates. 

In one large and handsomely printed volume, imperial octavo, with 520 pages. 

In this edition the plates have all been redrawn, and the text carefully read and corrected. It 
is therefore presented as in every way worthy the favor with which it has so long been received. 

From Professor Hodge, of the University of Pennsylvania. 
To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being the best 
authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout our country. 

We recommend the student, who desires to master this difficult subject with the least possible trouble, to 
possess himself at once of a copy of this work. — American Journal of the Medical Sciences. 

It stands at the head of the long list of excellent obstetric works published in the last few years in Great 
Britain, Ireland, and the Continent of Europe. We consider this book indispensable to the library of every 
physician engaged in the practice of Midwifery. — Southern Medical and Surgical Journal. 

When the whole profession is thus unanimous in placing such a work in the very first rank as regards the 
extent and correctness of all the details of the theory and practice of so important a branch of learning, our 
commenc ai ion or condemnation would be of little consequence; but, regardingit as the most useful of all works 
of the kind, we think it but an act of justice to urge its claims upon the profession.— N. O. Med. Journal. 



DEWEES'S JVMDWIFERY. 

A COMPREHENSIVE SYSTEM OP MIDWIFERY. 

ILLUSTRATED BY OCCASIONAL CASES AND MANY ENGRAVINGS. 
BY WILLIAM P. DEWEES, M. D. 

Tenth Edition, with the Author's last Improvements and Corrections. In one octavo volume, of 600 pages. 



BLANCHARD & LEA'S PUBLICATIONS— (Materia Medica and TJierapeutics.) 25 



PEREIRA'S MATERIA MEDICA— Vol. I.-(J\~otc Ready,) 
NEW EDITION, GREAT1Y IMPROVED AND ENLARGED. 

THIS ELEMENTS OF 

MATERIA MEDICA AND THERAPEUTICS, 

BY JONATHAN PEREIRA, M. D., F. K. S. and L. S. 

THIRD AMERICAN EDITION, 

ENLARGED AND IMPROVED BY THE AUTHOR, INCLUDING NOTICES OF MOST OF THE MEDICINAL SUB- 
STANCES IN USE IN THE CIVILIZED WORLD, AND FORMING AN ENCYCLOPEDIA OF 
MATERIA MEDICA. 

EDITED BY JOSEPH CARSON, M. D., 

Professor of Materia Medica and Pharmacy in ihe University of Pennsylvania. 
In two very large volumes, on small type, with about four hundred illustrations. 

The demand for this new edition of" Pereira's Materia Medica" has induced the publishers 
to issue the First Volume separately. The Second Volume, now at press, and receiving important 
corrections and revisions from both author and editor, may be shortly expected for publication. 

The third London edition of this work received very extensive alterations by the author. Many 
portions of it were entirely rewritten, some curtailed, others enlarged, and much new matter in- 
troduced in every part. The edition, however, now presented to the American profession, in 
addition to this, not only enjoys the advantages of a thorough and accurate superintendence by the 
editor, but also embodies the additions and alterations suggested by a further careful revision by 
the author, expressly for this country, embracing the most recent investigations, and the result of 
several new Pharmacopoeias which have appeared since the publication of the London edition of 
Volume I. The notes of the American editor have been prepared with reference to the new edi- 
tion of the U. S. Pharmacopoeia, and contain such matter generally as is requisite to adapt it fully 
to the wants of the profession in this country, as well as such recent discoveries as have escaped 
the attention of the author. In this manner the size of the work has been materially enlarged, 
and the number of illustrations much increased, while its mechanical execution has been greatly 
improved in every respect. The profession may therefore rely on being able to procure a work 
which, in every point of view, will not only maintain, but greatly advance the very high reputation 
which it has everywhere acquired. 

The work, in its present shape, and so far as can be judged from the portion before the public, forms the 
most comprehensive and complete treatise on materia medica extant in the English language. 

Dr. Pereira has been at great pains to introduce into his work, not only all the information on the natural, 
chemical, and commercial history of medicines, which might be serviceable to the physician and surgeon, 
but whatever might enable his readers to understand thoroughly the mode of preparing and manufacturing 
various articles employed either for preparing medicines, or for certain purposes in the arts connected with 
materia medica and the practice of medicine. 

The accounts of the physiological and therapeutic effects of remedies are given with great clearness and 
accuracy, and in a manner calculated to interest as well as instruct the reader. — The Edinburgh Medical 
and Surgical Journal. 

ROYLE'S MATERIA MEDICA. 

MATERIA MEDICA AND THERAPEUTICS; 

INCLUDING THE 

Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. 

WITH MANY NEW MEDICINES. 

BY J. FORBES BOYLE, M. D., F. R. S., 

Professor of Materia Medica and Therapeutics, King's College, London, &c. &c. 

EDITED BY JOSEPH CARSON, M. D., 

Professor of Materia Medica and Pharmacy in the University of Pennsylvania. 

WITH NINETY-EIGHT ILLUSTRATIONS. 

In one large octavo volume, of about seven hundred pages. 

Being one of the most beautiful Medical works published in this country. 

This work is, indeed, a most valuable one, and will fill up an important vacancy that existed between Dr. 
Pereira's most learned and complete system of Materia Medica, and the class of productions on the other ex- 
treme, which are necessarily imperfect from their small extent.— British and Foreign Medical Review. 



POCKET DISPENSATORY AND FORMULARY. 

A DISPENSATORY AND THERAPEUTICAL REMEMBRANCER. Comprising the entire lists 
of Materia Medica, with every Practical Formula contained in the three British Pharmacopoeias. 
With relative Tables subjoined, illustrating by upwards of six hundred and sixty examples, the 
Extemporaneous Forms and Combinations suitable for the different Medicines. By JOHN 
MAYNE, M. D., L. R. C. S., Edin., &c. &c. Edited, with the addition of the formula? of the 
United States Pharmacopoeia, by R. EGLESFELD GRIFFITH, M. D. In one 12mo. volume, 
of over three hundred large pages. 
The neat typography, convenient size, and low price of this volume, recommend it especially to 

physicians, apothecaries, and students in want of a pocket manual. 



26 



BLANC HARD & LEA'S PUBLICATIONS.— {Materia Medica, <fc.) 



NEW UNIVERSAL FORMULARY.— (Lately Issued.) 

A TraiVERSAlT FOBMULABY, 

CONTAINING THE 

METHODS OF PREPARING AND ADMINISTERING 

OFFICINAL AND OTHER MEDICINES. 

THE WHOLE ADAPTED TO PHYSICIANS AND PHARMACEUTISTS. 
BY K. EGLESFELD GRIFFITH, M. D., 

Author of "American Medical Botany," &c. 
In one large octavo volume of 568 pages, double columns. 

In this work will be found not only a very complete collection of formulae and pharmaceutic 
processes, collected with great care from the best modern authorities of all countries, but also a 
vast amount of important information on all collateral subjects. To insure the accuracy so neces- 
sary to a work of this nature, the sheets have been carefully revised by Dr. Robert Bridges, while 
Mr. William Procter, Jr., has contributed numerous valuable formulae, and useful suggestions. 

The want of a work like the present has long been felt in this country, where the physician and 
apothecary have hitherto had access to no complete collection of formulas, gathered from the 
pharmacopoeias and therapeutists of all nations. Not only has this desideratum been thoroughly 
accomplished in this volume, but it will also be found to contain a very large number of recipes for 
empirical preparations, valuable to the apothecary and manufacturing chemist, the greater part of 
which have hitherto not been accessible in this country. It is farther enriched with accurate ta- 
bles of the weights and measures of Europe ; a vocabulary of the abbreviations and Latin terms 
used in Pharmacy; rules for the administration of medicines ; directions for officinal preparations ; 
remarks on poisons and their antidotes ; with various tables of much practical utility. To facili- 
tate reference to the whole, extended indices have been added, giving to the work the advantages 
of both alphabetical and systematic arrangement. 

To show the variety and importance of the subjects treated of, the publishers subjoin a very 
condensed 

SUMMARY OF THE CONTENTS, IN ADDITION TO THE FORMULARY PROPER, 
WHICH EXTENDS TO BETWEEN THREE AND FOUR HUNDRED LARGE DOUBLE- 
COLUMNED PAGES. 



PREFACE. 
INTRODUCTION. 

Weights and Measures. 
Weights of the United States and GreatBritain. — 
Foreign Weights.— Measures. 

Specific Gravity. 

Temperatures for certain Pharmaceutical Ope- 
rations. 

Hydrometrical Equivalents. 

Specific Gravities of some of the Preparations 
of the Pharmacopoeias. 

Relation between different Thermometrical 
Scales. 

Explanation of principal Abbreviations used in 
Formula. 

Vocabulary of Words employed in Prescriptions. 
Observations on the Management of the Sick room. 
Ventilation of the Sick room. — Temperature of 
the Sick room —Cleanliness in the Sick room — 
Quiet in the Sick room.— Examination and Pre- 
servation of the Excretions.— Administration of 
Medicine.— Furniture of a Sick room.— Proper 
use of Utensils for Evacuations. 

Doses of Medicines. 
Age. — Sex. — Temperament. — Idiosyncrasy. — 
Habit.— State of the System.— Time of day.— In- 
tervals between Doses. 

Rules for Administration of Medicines. 
Acids. — Antacids. — Antilithics and Lithontriptics. 
Antispasmodics — Anthelmintics. — Cathartics.— 
Enemata — Suppositories.— Demulcents or Emol- 
lienis. — Diaphoretics. — Diluents. — Diuretics. — 
Emetics. — Emmenagogues. — Epispastics. — Er- 
rhiiies. — Escharotics. — Expectorants. — Narco- 
tics. — Refrigerants. — Sedatives. — Sialagogues. — 
Stimulants. — Tonics. 

Management of Convalescence and Relapses. 



DIETETIC PREPARATIONS NOT INCLUDED 
AMONG THE PREVIOUS PRESCRIPTIONS. 
LIST OF INCOMPATIBLES. 

POSOLOGICAL TABLES OF THE MOST IM- 
PORTANT MEDICINES. 
TABLE OF PHARMACEUTICAL NAMES 
WHICH DIFFER IN THE U. STATES 
AND BRITISH PHARMACOPOEIAS. 
OFFICINAL PREPARATIONS AND DIREC- 
TIONS. 
Internal Remedies. 
Powders.— Pills and Boluses.— Extracts.— Con- 
fections, Conserves, Electuaries— Pulps.— Sy- 
rups.— Mellites or Honeys.— Infusions.— Decoc- 
tions.— Tinctures.— Wines.— Vinegars.-Mixtures. 
Medicated Waters.— Distilled, Essential, or Vola- 
tile Oils.— Fixed Oils and Fats. — Alkaloids.- 
Spirits. — Troches or Lozenges. — Inhalations. 
External Remedies. 
Baths— Cold Bath.— Cool Bath.— Temperate Bath. 
—Tepid Bath— Warm Bath— Hot Bath.— Shower 
Bath.— Local Baths —Vapor Bath.— Warm Air 
Bath.— Douches.— Medicated Baths —Affusion- 
Sponging.— Fomentations.— Cataplasms, or Poul- 
tices. — Lotions, Liniments, Embrocations — Vesi- 
catories, or Blisters.— Issues. — Setons. — Oint- 
ments.— Cerates.— Piasters.— Fumigations. 

Bloodletting. 
General Bloodletting. —Venesection. — A rterio- 
tomy. — Topical Bloodletting — Cupping. -Leech- 
ing.— Scarifications. 
POISONS. 

INDEX OF DISEASES AND THEIR REMEDIES. 
INDEX OF PHARMACEUTICAL AND BOTANI- 
CAL NAMES. 
GENERAL INDEX. 



From the condensed summary of the contents thus given it will be seen that the completeness 
of this work renders it of much practical value to all concerned in the prescribing or dispensing 
of medicines. 



BLANCHARD & LEA'S PUBLICATIONS— {Materia Medica, $c.) 27 



GRIFFITH'S MEDICAL FORMULARY— (Continued.) 

From a vast number of commendatory notices, the publishers select a few. 

A valuable acquisition to the medical practitioner, and a useful book of reference to the apothecary on 
numerous occasions. — American Journal of Pharmacy. 

Dr. Griffith's Formulary is worthy of recommendation, not only on account of the care which has been 
bestowed on it by its estimable author, but for its general accuracy, and the richness of its details.— Medical 
Examiner. 

Most cordially we recommend this Universal Formulary, not forgetting its adaptation to druggists and 
apothecaries, who would find themselves vastly improved by a familiar acquaintance with this every-day 
book of medicine. — The Boston Medical and Surgical Journal. 

Pre-eminent among the best and most useful compilations of the present day will be found the work before 
us, which can have been produced only at a very great cost of thought and labor. A short description will 
suffice to show that we do not put too high an estimate on this work. We are not cognizant of the existence 
of a parallel work. Its value will be apparent to our readers from the sketch of its contents above given. 

We strongly recommend it to all who are engaged either in practical medicine, or more exclusively with 
its literature. — London Medical Gazette. 

A very useful work, and a most complete compendium on the subject of materia medica. We know of no 
work in our language, or any other, so comprehensive in all its details. — London Lancet. 

The vast collection of formula; which is offered by the compiler of this volume, coniains a large number 
which will be new to English practitioners, some of ihem from the novelty of their ingredients, and others 
from the unaccustomed mode in which they are combined; and we douht not that several of these might be 
advantageously brought into use. The authority for every formula is given, and the list includes a very nu- 
merous assemblage of Continental, as well as of British and American writers of repute. It is. therefore, 
a work to which every practitioner may advantageously resort for hints to increase his stock of remedies 
and of forms of prescription. 

The other indices facilitate reference to every article in the "Formulary;" and they appear to have been 
drawn up with the same care as that which the author has evidently bestowed on every part of the work — 
The British and Foreign Medico- Chirurgical Revitio. 

The work before us is all that it professes to be. viz.: " a compendious collection of formulre and pharma- 
ceutic processes." It is such a work as was much needed, and should he in the hands of every practitioner 
who is in the habit of compounding medicines.— Transylvania Medical Journal 

This seems to be a very comprehensive work, so far as the range of its articles and combinations is con- 
cerned, with a commendable degree of brevity and condensation in their explanation. 

It cannot fail to be a useful and convenient book of reference to the two classes of persons to whom it 
particularly eoinini'iuls itself in the title-page.— The N. \V. Medical a, id Surgical Journal. 

It contains so much information that we very cheerfully recommend it to the profession.— Charleston Med. 
Journal. 

Well adapted to supply the actual wants of a numerous and varied class of persons.— N. Y. Journal of 
Medicine. 

CHRISTISON & GRIFFITH'S DISPENSATORY.- (A New Work.) 

A DISPENSATORY, 

OR, COMMENTARY ON THE PHARMACOPOEIAS OF GREAT BRITAIN AND THE UNITED 

STATES: COMPRISING THE NATURAL HISTORY, DESCRIPTION, CHEMISTRY, 

PHARMACY, ACTIONS, USES, AND DOSES OF THE ARTICLES OF 

THE MATERIA MEDICA. 

BY ROBERT CHRISTISON, M. J)., V. P. R. S. E., 

President of the Royal College of Physicians of Edinburgh ; Professor of Materia Medica in the University 

of Edinburgh, etc. 

Second Edition, Revised and Improved, 

WITH A SUPPLEMENT CONTAINING THE MOST IMPORTANT NEW REMEDIES. 

WITH COPIOUS ADDITIONS, 

AND TWO HUNDRED AND THIRTEEN LARGE WOOD ENGRAVINGS. 

BY R. EGLESFELD GRIFFITH, M. D., 

Author of "A Medical Botany," etc. 

In one very large and handsome octavo volume, of over one thousand closely-printed pages, with 

numerous wood-cuts, beautifully printed on fine white paper, presenting an immense 

quantity of matter at an unusually low price. 

It is enough to say that it appears to us as perfect as a Dispensatory, in the present state of pharmaceuti- 
cal science, could be made. — The Western Journal of Medicine and Surgery. 

CMBSOWS Sl"J\~OrsrS—(J\*otc Beady.) 

synopsis"of the 
COURSE OF LECTURES ON MATERIA MEDICA AND PHARMACY, 

Delivered in the University of Pennsylvania. 

BY JOSEPH CARSON, M. D., 

Professor of Materia Medica and Pharmacy in the University of Pennsylvania. 
In one very neat octavo volume of 208 pages. 
This work, containing a rapid but thorough outline of the very extensive subjects under consideration, will 
be found useful, not only for the matriculants and graduates of ihe institution for whom it is more particu- 
larly intended, but also for those members of the profession who may desire to recall their former studies. 

THE THREE KINDS OF COD-LIVER OIL, 

Comparatively considered, with their Chemical and Therapeutic Properties, by L. J. DE JONGH, 
M. D. Translated, with an Appendix and Cases, by EDWARD CAREY, M.D. To which is 
added an article on the subject from " Dunglison on New Remedies." In one small 12mo. 
volume, extra cloth. 



28 BLANCHARD & LEA'S PUBLICATIONS.— (Materia Medica and Therapeutics.) 

DUNGLISON'S THERAPEUTICS. 
MEW AID IMPROVED EDITION.— (Eately Issued.) 

GENERAL THERAPEUTICS AND MATERIA MEDICA; 

ADAPTED FOR A MEDICAL TEXT-BOOK, 

BY KOBLEY DUNGLISON, M. D., 

Professor of Institutes of Medicine, &c, in Jefferson Medical College ; Late Professor of Materia Medica, &c. 
in the Universities of Maryland and Virginia, and in Jefferson Medical College. 

FOURTH EDITION, MUCH IMPROVED. 

With One Hundred and Eighty-two Illustrations. 

In two large and handsomely printed octavo volumes. 

The present edition of this standard work has been subjected to a thorough revision both as re- 
gards style and matter, and has thus been rendered a more complete exponent than heretofore of 
the existing state of knowledge on the important subjects of which it treats. The favor with which 
the former editions have everywhere been received seemed to demand that the present should be 
rendered still more worthy of the patronage of the profession, and of the medical student in particu- 
lar, for whose use more especially it is proposed; while the number of impressions through which 
it has passed has enabled the author so to improve it as to enable him to present it with some de- 
gree of confidence as well adapted to the purposes for which it is intended. In the present edition, 
the remedial agents of recent introduction have been inserted in their appropriate places ; the 
number of illustrations has been greatly increased, and a copious index of diseases and remedies 
has been appended, improvements which can scarcely fail to add to the value of the work to the 
therapeutical inquirer. 

The publishers, therefore, confidently present the work as it now stands to the notice of the 
practitioner as a trustworthy book of reference, and to the student, for whom it was more especially 
prepared, as a full and reliable text-book on General Therapeutics and Materia Medica. 

Notwithstanding the increase in size and number of illustrations, and the improvements in the 
mechanical execution of the work, its price has not been increased. 

In this work of Dr. Dunglison, we recognize the same untiring industry in the collection and embodying of 
facts on the several subjects of which he treats, that has heretofore distinguished him, and we cheerfully 
point to these volumes, as two of the most interesting that we know of. In noticing the additions to this, the 
fourth edition, there is very little in the periodical or annual literature of the profession, published in the in- 
terval which has elapsed since the issue of the first, that has escaped the careful search of the author. As 
a book for reference, it is invaluable. — Charleston Med. Journal and Review. 

It may be said to be the work now upon the subjects upon which it treats. — Western Lancet. 

As a text book for students, for whom it is particularly designed, we know of none superior to it.— St. 
Louis Medical and Surgical Journal. 

It purports to be a new edition, but it is rather a new book, so greatly has it been improved both in the 
amount and quality of the matter which it contains. — N. O. Medical and Surgical Journal. 

We bespeak for this edition from the profession an increase of patronage over any of its former ones, on 
account of its increased merit. — N. Y. Journal of Medicine. 

We consider this work unequalled.— Boston Med. and Surg. Journal. 



NEW AND MUCH IMPROVED EDITION— Brought up to 1851.— (Just Issued.) 

NEW REMEDIES, 

WITH FORMULAE FOR THEIR ADMINISTRATION, 

BY ROBLEY DUNGLISON, M. D., 

PROFESSOR OF THE INSTITUTES OF MEDICINE, ETC. IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA. 

Sixth Edition, -with extensive Additions. 

In one very large octavo volume, of over seven hundred and fifty pages. 

The fact that this work has rapidly passed to a SIXTH EDITION is sufficient proof that it has supplied a 
desideratum to the profession in presenting them with a clear and succinct account of all new and impor- 
tant additions to the materia medica, and novel applications of old remedial agents. In the preparation of 
the present edition, the author has shrunk from no labor to render the volume worthy of a continuance of the 
favor with which it has been received, as is sufficiently shown by the increase of about one hundred pages 
in the size of the work. The necessity of such large additions arises from the fact that the last few years 
have been rich in valuable gifts to Therapeutics; and amongst these, ether, chloroform, and other so called 
anaesthetics, are worthy of special attention. They have been introduced since the appearance of the last 
edition of the " New Remedies." Other articles have been proposed for the first time, and the experience of 
observers has added numerous interesting facts to our knowledge of the virtues of remedial agents pre- 
viously employed. 

The therapeutical agents now first admitted into this work, some of which hava been newly introduced 
into pharmacology, and the old agents brought prominently forward with novel applications, and which may 
consequently be regarded as New Remedies, are the following :— Adansonia digitata, Benzoate of Ammonia, 
Valerianate of Bismuth, Sulphate of Cadmium, Chloroform, Collodion, Cantharidal Collodion, Cotyledon Um- 
bilicus, Sulphuric Ether, Strong Chloric Ether, Compound Ether, Hura Braziliensis, Iberis Amara, Iodic 
Acid, Iodide of Chloride of Mercury, Powdered Iron, Citrate of Magnetic Oxide of Iron, Citrate of Iron and 
Magnesia, Sulphate of Iron and Alumina, Tannate of Iron, Valerianate of Iron, Nitrate of Lead, Lemon 
Juice, Citrate of Magnesia, Salts of Manganese, Oleum Cadinum, Arsenite of Quinia, Hydriodate of Iron and 
Quinia, Sanicula Marilanaica, and Sumbul. 



BLANCHARD & LEA'S PUBLICATIONS.— (Materia Medica, &c. 29 



MOIIK, REDWOOD, AND PROCTER'S PHARMACY.- Lately Issued. 

PRACTICAL "PHAEMACY. 

COMPRISING THE ARRANGEMENTS, APPARATUS, AND MANIPULATIONS OF THE 
PHARMACEUTICAL SHOP AND LABORATORY. 

BY FRANCIS MOHR, Ph.D., 

Assessor Pharmacia; of the Royal Prussian College of Medicine, Coblentz; 

AND THEOPHILUS REDWOOD, 

Professor of Pharmacy in the Pharmaceutical Society of Great Britain. 

EDITED, WITH EXTENSIVE ADDITIONS, BY PROFESSOR WILLIAM PROCTER, 

Of the Philadelphia College of Pharmacy. 

In one handsomely printed octavo volume, of 570 pages, with over 500 engravings on wood. 

To physicians in the country, and those at a distance from competent pharmaceutists, as well as 
to apothecaries, this work will be found of great value, as embodying much important information 
which is to be met with in no other American publication. 

After a pretty thorough examination, we can recommend it as a highly useful book, which should 
be in the hands of every apothecary. Although no instruction of this kind will enable the beginner to 
acquire that practical skill and readiness which experience only can confer, we believe that this work will 
much facilitate their acquisition, by indicating means for the removal of difficulties as they occur, and sug- 
gesting methods of operation in conducting pharmaceutic processes which the experimenter would only 
lit upon after many unsuccessful trials; while there are few pharmaceutists, of however extensive expe- 
rience, who will not find in it valuable hints that they can turn to use in conducting the affairs of the shop 
and laboratory. The mechanical execution of the work is in a style of unusual excellence. It contains 
about five hundred and seventy large octavo pages, handsomely printed on good paper, and illustrated by 
over five hundred remarkably well-execuied wood-cuts of chemical and pharmaceutical apparatus. It 
comprises the whole of Mohr and Redwood's book, as published in London, rearranged and classified by 
the American editor, who has added much valuable new matter, which has increased the size of the book 

ore than one-fourth, including about one hundred additional wood-cuts.— The American Journ. of Pharmacy. 

It is a book, however, which will be in the hands of almost every one who is much interested in pharma- 
ceutical operations, as we know of no other publication so well calculated to fill a void long felt.— The Medi- 
cal Examiner. 

The country practitioner who is obliged to dispense his own medicines, will find it a most valuable assist- 

it.— Monthly Journal and Retrospect. 

The book is strictly practical, and describes only manipulations or methods of performing the numerous 
processes the pharmaceutist has to go through, in the preparation and manufacture of medicines, together 
with all the apparatus and fixtures necessary thereto. On these matters, this work is very full and com- 
plete, and details, in a style uncommonly clear and lucid, not only the more complicated and difficult pro- 
cesses, but those not less important ones, the most simple and common. The volume is an octavo of five 
hundred and seventy-six pages. It is elegantly illustrated with a multitude of neat wood engravings, and 
is unexceptionable in its whole typographical appearance and execution. We take great satisfaction in 
commending this so much needed treatise, not only to those for whom it is more specially de«igned. but to 
the medical profession generally — to every one. who, in his practice, has occasion to prepare, as well as ad- 
minister medical agents. — Buffalo Medical Journal. 



JVEW Jt*vn COMPLETE MEDICAL, BOTJJS*l\ 

MEDICAL" BOTANY; 

OR. A DESCRIPTION OF ALL THE MORE IMPORTANT PLANTS USED IN MEDICINE, AND 

OF THEIR PROPERTIES, USES, AND MODES OF ADMINISTRATION, 

BY R. EGLESFELD GRIFFITH, M. D., &c. &c. 

In one large 8vo. vol. of 704 pages, handsomely printed, with nearly 350 illustrations on wood- 
One of the greatest acquisitions to American medical literature. It should by all means be introduced, at 
the very earliest period, into our medical schools, and occupy a place in the library of every physician in the 
land.— Southwestern Medical Advocate. 

Admirably calculated for the physician and student— we have seen no work which promises greater ad- 
vantages to the profession— N. O. Medical and Surgical Journal. 

One of the few books which supply a positive deficiency in our medical literature. — Western Lancet. 
We hope the day is not distant when this work will not only be a text-book in every medical school and 
eollege in the Union, but find a place in the library of every private practitioner.— N. Y. Journ. of Medicine. 



ELLIS'S MEDICAL FORMULARY.— Improved Edition. 

THE MEDICAL FORMULARY: 

BEING A COLLECTION OF PRESCRIPTIONS, DERIVED FROM THE WRITINGS AND PRACTICE OF MANY OF THE MOST 
EMINENT PHYSICIANS OF AMERICA AND EUROPE. 

To which is added an Appendix, containing the usual Dietetic Preparations and Antidotes for Foisons. 

THE WHOLE ACCOMPANIED WITH A FEW BRIEF PHARMACEUTIC AND MEDICAL OBSERVATIONS. 

BY BENJAMIN ELLIS, M. D. 

NINTH EDITION, CORRECTED AND EXTENDED, BY SAMUEL GEORGE MORTON, M. D. 

In one neat octavo volume of 268 pages. 



CARPENTER ON ALCOHOLIC LIQUORS. -(A New Work.) 

A Prize Essay on the Use of Alcoholic Liquors in Health and Disease. By William B. Carpenter, 
M. D., author of " Principles of Human Physiology," &c. In one 12mo. volume. 



30 BLANCHARD & LEA'S PUBLICATIONS.— {Chemistry.) 

NEW EDITION OF GRAJBAJBPS CMEJKISTRY—(JYow Read!/.) 

ELEMENTS OF CHEMISTRY; 

INCLUDING THE APPLICATIONS OF THE SCIENCE IN THE ARTS. 
BY THOMAS GRAHAM, F. Ft. S., &c. 

Second American, from the Second, entirely Revised, and greatly Enlarged London Edition. 
With Notes and Additions by ROBERT BRIDGES, M. D. 
To be complete in one very large octavo volume, with several hundred beautiful illustrations. 
PART I, now ready, of about 450 large pages, with 185 illustrations. 
PART II, completing the work, preparing for early publication. 

The great changes which the science of chemistry has undergone within the last few yea-rs, render a new 
edition of a treatise like the present almost a new work. Tne author has devoted several years to the revi- 
sion of his treatise, and has endeavored to embody in it every fact and inference of importance which has 
been observed and recorded by the great body of chemical investigators who are so rapidly changing the 
face of the science. In this manner the work has been greatly increased in size, and the number of illus- 
trations doubled ; while the labors of the editor have been directed towards the introduction of such matters 
as have escaped the attention of the author, or as have arisen since the publication of the first portion of this 
edition in London, in 1850 Printed in handsome style, and at a very low price, it is therefore confidently pre- 
sented to the profession and the student as a very complete and thorough text- book of this important subject. 

NEW AND IMPROVED EDITION— (lately Issued.) 

ELEMENTARY CHEMISTRY, 

THEORETICAL AND PRACTICAL. 

BY GEORGE FOWNES, Ph. D., ~ 

Chemical Lecturer in the Middlesex Hospital Medical School, &c. &c. 
WITH NUMEROUS ILLUSTRATIONS. 

THIRD AMERICAN, FROM A LATE LONDON EDITION. EDITED, WITH ADDITIONS, 

BY ROBERT BRIDGES, M. D., 

Professor of General and Pharmaceutical Chemistry in the Philadelphia College of Pharmacy, &c. &c. 
In one large royal 12mo. vol., of over 500 pages, with about 180 wood-cuts, sheep or extra cloth. 

The work of Dr. Fownes has long been before the public, and its merits have been fully appreciated as 
the best text-book on Chemistry now in existence. t We do not, of course, place it in a rank superior to the 
works of Braude, Graham, Turner, Gregory, or Grhelin, but we say that, as a work for students, it is prefer- 
able to any of them.— London Journal of Medicine. 

The rapid sale of this Manual evinces its adaptation to the wants of the student of chemistry, whilst the 
well known merits of its lamented author have constituted a guarantee for its value, as a faithful exposition 
of the general principles and most important facts of the science to which it professes to be an introduction. 
— The^British and Foreign Medico- Chirurgical Review. 

A work well adapted to the wants of the student. It is an excellent exposition of the chief doctrines and 
facts of modern chemistry, originally intended as a guide to the lectures of the author, corrected by his own 
hand shortly before his death in 1849, and recently revised by Dr. Bence Jones, who has made some additions 
to the chapter on animal chemistry. Although not intended to supersede the more extended treatises oa 
chemistry, Professor Fownes' Manual may, we think, be often used as a work of reference, even by those 
advanced in the study, who may be desirous of refreshing their memory on some forgotten point. The size 
of the work, and still more the condensed yet perspicuous style in which it is written, absolve it from the 
cliarges very properly urged against most manuals termed popular, viz., of omitting details of indispensable 
importance, of avoiding technical difficulties, instead of explainingthem, and of treating subjects of high sci- 
entific interest in an unscientific way .—Edinburgh Monthly Journal of Medical Science. 

BOWMAN'S MEDICAL CHEMISTRY- (Lately Issued.) 

PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. 

BY JOHN E. BOWMAN, M. D. 

In one neat volume, royal 12mo., with numerous illustrations. 

Mr. Bowman has succeeded in supplying a desideratum in medical literature. In the little volume before 
us, he has given a concise but comprehensive account of all matters in chemistry which the man in practice 
raav desire to know. — Lancet. 



BY THE SAME AUTHOR- (Lately Issued.) 
INTRODUCTION TO PRACTICAL CHEMISTRY, Including Analysis. 

With Numerous Illustrations. In one neat volume, royal 12mo. 
GARDNER'S MEDICAL CHEMISTRY. 

MEDICAL CHEMISTRY, 

FOR THE USE OF STUDENTS AND THE PROFESSION; 

BEING A MANUAL OF THE SCIENCE. WITH ITS APPLICATIONS TO TOXICOLOGY, 
PHYSIOLOGY, THERAPEUTICS, HYGIENE, &c. 

BY D. PEREIRA GARDNER, M. D. 

In one handsome royal 12mo. volume, with illustrations. 



SIMON'S ANIMAL CHEMISTRY, with Reference to the Physiology and Pathology 
of Man. By G. E. Day. One vol. 87©., 700 pages. 



BLANCIIARD & LEA'S PUBLICATIONS. 31 

TAYLOR'S MEDICAL, JURISPItUDEJTCE. 

MEDICAL JURISPRUDENCE. 

BY ALFRED S. TAYLOK, 

SECOx\D AMERICAN, FROM THE THIRD AND ENLARGED LONDON EDITION. 

With numerous Notes and Additions, and References to American Practice and Law. 

BY R. E. GRIFFITH, M. D. 

In one large octavo volume. 

This work has been much enlarged by the author, and may now be considered as the standard 
authority on the subject, both in England and this country. It has been thoroughly revised, in 
this edition, and completely brought up to the day with reference to the most recent investigations 
and decisions. No further evidence of its popularity is needed than the fact of its having, in the 
short time that has elapsed since it originally appeared, passed to three editions in England, and 
two in the United States. 

We recommend M r. Taylor's work as the ablest, most comprehensive, and, above all, the most practically 
useful book which exists on the subject of legal medicine. Any man of sound judgment, who ha* mastered 
the contents of Taylor's " Medical Jurisprudence," may go into a conn of law with the most perfect confi- 
dence of being able to acquit himself creditably.— Medico- Chirurgical Review. 

The most elaborate and complete work that has yet appeared. It contains an immense quantity of cases 
lately tried, which entitle it to be considered what Beck was in its day. — Dublin Medical Journal. 



TAYLOR ON POISON'S. 

ON POISONS, 

IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. 

BY ALFRED S. TAYLOR, F. R. S., &o. 

Edited, with Notes and Additions, BY R. E. GRIFFITH, M. D. 

In one large octavo volume, of 688 pages. 

The most elaborateworkonthe subject that our literature y>os>cs*ts.— Un'/.o nd For. M'dico-Chirur Rn-iett. 

One of the most practical and trustworthy works on Poisons in our language. — We$tern Journal of Med. 

It contains a vast body of facts, which embrace all that is important in toxicology, all that is necessary to 

the guidance of the medical jurist, and all that can be desired by the lawyer.— Medico-Chirurgiral Review. 

It is, so far as our knowledge extends, incomparably the best upon the subject ; in the highest degree credit- 
able to the author, entirely trustworthy, and indispensable to the student and practitioner.— N. Y. Annalist. 



A NEW WORK ON THE SKIN— (Nearly Ready.) 

A PRACTICAL TREATISE ON DISEASES OF THE SKIN, 

BY J. M. NELIGAN, M. D., 

Author of "Medicines, their Uses and Modes of Administration. '" Ace. 
In one neat volume, royal 12mo. 



THE LAWS OF HEALTH IN RELATION TO MIND ANH BODY. 

A SERIES OF LETTERS FROM AN OLD PRACTITIONER TO A PATIENT. 

BY LIONEL JOHN BEALE, M. R. C. S., &c. 

Ln one handsome volume, royal l2mo., extra cloth. 



LETTERS TO A CANDID INQUIRER. 

ON ANIMAL MAGNETISM. 

BY WILLIAM GREGORY, M. D., F. R, S. E., 

Professor of Chemistry in the University of Edinburgh, &c. 
In one neat volume, royal 12mo., extra cloth. 



PROFESSOR DICKSON'S ESSAYS, 

ESSAYS ON LIFE, SLEEP, PAIN, INTELLECTION, HYGIENE, AND DEATH. 
BY SAMUEL HENRY DICKSON, M.D., 

Professor of the Institutes and Practice of .Medicine in the Charleston Medical College. 
In one very handsome volume, royal 12mo. 



DUNGLISON ON HUMAN HEALTH —HUMAN HEALTH,or the Influence of Atmosphere and Locality, 
Change of Air and Climate, Seasons, Food, Clothing. Bathing. Exercise. Sleep, &c. &e. &c, on healthy 
man; constituting Elements of Hygiene. Second edition, with many modifications and additions. By 
Robley Dunglison, M. D., &c. &c. In one octavo volume of 464 pages. 

DUNGLISON'S MEDICAL STUDENT.— The Medical Student, or Aids to the Study of Medicine. Revised 
and Modified Edition. 1 vol. royal 12mo. extra cloth. 312 pp. 

BARTLETT'S PHILOSOPHY OF MEDICINE.— An Essay on the Philosophy of Medical Science. In 
one handsome Svo volume. 312 pp. 

BARlLEtT ON CERTAINTY IN MEDICINE— An Inquiry into the Degree of Certainty in Medicine, 
and into the Nature and Extent of its Power over Disease. In one vol. royal 12mo. 84 pp. 



32 BLANCHARD & LEA'S PUBLICATIONS. 

THE GREAT AMERICAN MEDICAL DICTIONARY. 
New and Enlarged Edition — (Now Ready.) 

MEDICAL "LEXICON ; 

A DICTIONARY OF MEDICAL SCIENCE, 

Containing a Concise Explanation of the various Subjects and Terms of 

PHYSIOLOGY, PATHOLOGY, HYGIENE, THERAPEUTICS, PHARMACOLOGY, 
OBSTETRICS, MEDICAL JURISPRUDENCE, &c. 

WITH THE FRENCH AND OTHER SYJVOtfYMES. 

NOTICES OF CLIMATE AND OF CELEBRATED MINERAL WATERS; 
Formulae for various Officinal, Empirical, and Dietetic Preparations, &c. 

BY ROBLEY DUNGLISON, M. D., 

Professor of Institutes of Medicine, &c. in Jefferson Medical College, Philadelphia, &c. 

EIGHTH EDITION, 

REVISED AND GREATLY ENLARGED. 

In one very thick 8vo. vol., of 927 large double-columned pages, strongly bound, with raised bands. 

Every successive edition of this work bears the marks of the industry of the author, and of his determina- 
tion to keep it fully on a level with the most advanced state of medical science. Thus the last two editions 
contained about nine thousand subjects and terms not comprised in the one immediately preceding, and the 
present has not less than fou» thousand not in any former edition. As a complete Medical Dictionary, 
therefore, embracing over fifty thousand definitions, in all the branches of the science, it is presented as 
meriting a continuance of the great favor and popularity which have carried it, within no very long space of 
time, to an eighth edition. 

Every precaution has been taken in the preparation of the present volume, to render its mechanical exe- 
cution and typographical accuracy worthy of its extended reputation and universal use. The very exten- 
sive additions have been accommodated, without materially increasing the bulk of the volume, by the employ- 
ment of a small but exceedingly clear type, cast for this purpose. The press has been watched with great 
care, and every effort used to insure the verbal accuracy so necessary to a work of this nature. The whole 
is printed on fine white paper; and while thus exhibiting in every respect so great an improvement over 
former issues, it is presented at the original exceedingly low price. 

On the appearance of the last edition of this valuable work, we directed the attention of our readers to its 
peculiar merits ; and we need do little more than state, in reference to the present re-issue, that notwith- 
standing the large additions previously made to it, no fewer than four thousand terms, not to be found in the 
preceding edition, are contained in the volume before us. Whilst it is a wonderful monument of its author's 
erudition and industry, it is also a work,of great practical utility, as we can testify from our own expe- 
rience ; for we keep it constantly within our reach, and make very frequent reference to it, nearly always 
finding in it the information we seek. — British and Foreign Medico- Chirurgical Review, April, 1852. 

Dr. Dunglison's Lexico* has the rare merit that it certainly has no rival in the English language for ac- 
curacy and extent of references. The terms generally include short physiological and pathological de- 
scriptions, so that, as the author justly observes, the reader does not possess in this work a mere dictionary, 
but a book, which, while it instructs him in medical etymology, furnishes him with a large amount of useful 
information. That we are not over-estimating the merits of this publication, is proved by the fact that we 
have now before us the seventh edition. This, at any rate, shows that the author's labors have been pro- 
perly appreciated by his own countrymen ; and we can only confirm their judgment, by recommending this 
most useful volume to the notice of our cisatlantic readers. No medical library will be complete without it. 
— The London Med. Gazette. 

It is certainly more complete and comprehensive than any with which we are acquainted in the English 
language. Few, in fact, could be found better qualified than Dr. Dunglison for the production of such a work. 
Learned, industrious, persevering, and accurate, he brings to the task all the peculiar talents necessary for 
its successful performance : while, at the same time, his familiarity with the writings of the ancient and 
modern " masters of our art," renders him skilful to note the exact usage of the several terms of science, and 
the various modifications which medical terminology has undergone with the change of theories or the pro- 
gress of improvement. — American Journal of the Medical Sciences. 

One of the most complete and copious known to the cultivators of medical science. — Boston Med. Journal. 

This most complete Medical Lexicon— certainly one of the best works of the kind in the language. — 
Charleston Medical Journal. 

The most complete Medical Dictionary in the English language. — Western Lancet. 

Dr. Dunglison's Dictionary has not its superior, if indeed its equal, in the English language.— Si. Lout's 
Med. and Surg. Journal. 

Familiar with nearly all the medical dictionaries now in print, we consider the one before us the most 
complete, and an indispensable adjunct to every medical library. — British American Medical Journal. 

We repeat our former declaration that this is the best Medical Dictionary in the English language. — 
Western Lancet. 

We have no hesitation to pronounce it the very best Medical Dictionary now extant.— Southern Medical 
and Surgical Journal. 

The most comprehensive and best English Dictionary of medical terms extant.— Buffalo Med. Journal, 



HOBLYN'S MEDICAL DICTIONARY. 

A DICTIONARY OF THE TERMS USED IN MEDICINE 

AND THE COLLATERAL SCIENCES. 
BY RICHARD D. HOBLYN, A. M., Oxon. 

REVISED. WITH NUMEROUS ADDITIONS, FROM THE SECOND LONDON EDITION, 
BY ISAAC HAYS, M. D., &c. In one large royal 12mo. volume of 402 pages, double columns. 
We cannot too strongly recommend this small and cheap volume to the library of every student and prac- 
titioner.— Medico- Chirurgical Review. 



iE 9 



